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

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.”

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.”

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”