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. 2018 Mar 13;68(669):e279–e285. doi: 10.3399/bjgp18X695489
Category of patient safety issue or action required on case note review Example of action required
Incorrect coding
  • Clinical conditions coded accurately

  • Abnormal results coded as normal

Action required but not taken
  • Results coded as abnormal but not actioned

  • Patient advised to go for test following abnormal result but test not undertaken

Routine monitoring not done
  • Monitoring necessary for safe prescribing of medication

  • Medication reviews

  • Review of efficacy of prescribed medication

Investigations
  • Repeating investigations in the surgery

  • Referrals for further investigation in hospital or community clinic

Medication changes
  • Stopping medication because of safety concerns

  • Cleaning up repeat medication lists

  • Stopping medication due to side effects

Clinical contact
  • Bringing in patients for clinical review

  • Discussion with patients around new diagnoses and provision of information