Insufficient assessment reports | |||
Common Contributory Factors | Common Outcomes | Harm Severity | Example of Report Delayed diagnosis of intracranial bleed |
• Inadequate skill set/knowledge (n = 510, 70%) • Clinician “mistake” (n = 192, 26%) • Failure to follow protocol (n = 71, 10%) | • Delay in management/assessment (n = 659, 91%) • Repeated healthcare visits (n = 327, 45%) • General deterioration/progress of condition (n = 157, 22%) | 353 reports assessed for harm outcome • No harm (n = 48, 14%) • Mild harm (n = 200, 57%) • Moderate harm (n = 52, 15%) • Severe harm (n = 16, 4%) • Death (n = 37, 10%) | “Patient attended the Emergency department with a head injury. Physician did not undertake neurological observations. Patient reported headache two days post head injury. Lack of assessment by a physician meant that guidelines for head injury were not met and that intracranial bleed was missed.” |
Inappropriate response to diagnostic imaging reports | |||
Common Contributory Factors | Common Outcomes | Harm Outcomes | Example of Report Delayed diagnosis of cervical-spine fracture |
• Mistake in interpretation of imaging (n = 463, 81%) • Inadequate skill set/knowledge (n = 352, 62%) • Task to be completed by the clinician (e.g. checking patient notes) (n = 30, 5%). | • Delay in management/assessment occurred (n = 476, 84%) • Repeated healthcare visits (n = 251, 44%) • General deterioration/progress of condition occurred (n = 55, 10%) | 197 reports assessed for harm outcome • No harm (n = 55, 28%) • Mild harm (n = 104, 53%) • Moderate harm (n = 21, 11%) • Severe harm (n = 6, 3%) • Death (n = 11, 5%) | “A 75 year-old lady was seen after a fall. She had a Cervical-spine X-ray done which was interpreted as normal. The patient was admitted in Emergency department and discharged the next day. I received a call regarding a missed fracture of C2 (2nd cervical vertebrae). The patient had been admitted at another hospital.” |
Failure to order diagnostic imaging reports | |||
Common Contributory Factors | Common Contributory Factors | Harm Outcomes | Example of Report Delayed diagnosis of hip fracture |
• Clinician “mistake” (n = 32, 17%) • Failure to follow protocol (n = 30, 16%). | • Delay in management (n = 140, 75%) • Repeated visits to/from healthcare providers (n = 67, 36%) | 62 reports assessed for harm outcomes • No harm (n = 11, 18%) • Mild harm (n = 33, 53%) • Moderate harm (n = 7, 11%) • Severe Harm (n = 2, 3%) • Death (n = 9, 15%) | “Patient attended emergency department documented on initial assessment that leg shortened and rotated. Patient not x-rayed, sent to Emergency department unit for mobilisation. Unable to mobilise and leg shortened and rotated - X-Ray shows peri-prosthetic hip fracture” |