Table 2.
Stage one 2016 examples (subset of 21 observations analysed 13 incorrect codes)
| Code theme | Description | Error or Threat | Student correct in E or T | Number |
|---|---|---|---|---|
| Infection | • Consultant not washing hands between patients | T | Incorrect | 1 |
| • Failure of medical staff to change uniform/dress is a threat to other patients | T | Correct | 1 | |
| Insufficient skills | • Operation where staff had not recognised the drill setting before starting | T | Incorrect | 1 |
| Wrong patient | • Similar patient’s consultant confuses the patients corrected by Registrar | T | Incorrect | 1 |
| Privacy and dignity | • Curtain not fully pulled around patient during a ward round | T | Incorrect | 1 |
| • Sensitive information spoken loudly at the ward desk | T | Incorrect | 1 | |
| Slow computers | • Issues with slow computers | T | Correct | 1 |
| Technology | • No dicta-phone available | T | Correct | 1 |
| Layout design | • Layout design of clinic | T | Correct | 1 |
| Equipment | • Needed help to identify the right equipment before surgery—pieces missing | T | Incorrect | 1 |
| Guidelines not followed | • Changing uniform/clinical dress in isolation wards between seeing different patients | E | Undefined | 1 |
| Poor professionalism | • Management of discharge—varicose veins | T | Incorrect | 1 |
| Confidentiality and Patient-centred care | • Junior doctor dictating notes with door open | T | Incorrect | 1 |
| Checking | • Patient who was not sent his operation date—took a year—administrative error | T | Incorrect | 1 |
| Systems issues | • Transferring data from paper to IT prescribing | T | Correct | 1 |
| • The white board was not up dated at handover | T | Incorrect | 1 | |
| • Bed shortages and problems with transfer of patient back to ward from ITU | T | Correct | 1 | |
| Team communication | • Junior doctor not prepared for the ward round and had to go back and gather more data | T | Incorrect | 1 |
| • Nurse joining a ward/team meetings out of sequence with which patient is being discussed and wrong information given corrected by consultant | T | Correct | 1 | |
| Excluded data wrongly included neither error or threat | ||||
| Error or Threat | Issues raised | |||
| T | Recorded as slow computers, whereas the installation of dictate software by a new clinician is a normal process. If we had had a chat as a team, this understanding about a normal processes could have been relayed. | |||
| E | Transfer of patient to the ward during the night from ITU is normal practice and within hospital protocol | |||