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Table 2 Contributory factors, outcomes and examples for key contributory incident types

From: Diagnostic error in the emergency department: learning from national patient safety incident report analysis

Insufficient assessment reports
Common Contributory
Factors
Common OutcomesHarm SeverityExample 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 FactorsCommon OutcomesHarm OutcomesExample 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 FactorsCommon Contributory FactorsHarm OutcomesExample 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”