Skip to main content

Table 3 Examples of patient safety incidents

From: Patient safety in out-of-hours primary care: a review of patient records

Incident type Study example
Treatment A patient visited the GP cooperative with a metal foreign body in his eye. GP removed splinter and sent patient home. After four hours, the patient called the GP cooperative because of increasing pain in the eye. At patient's initial visit, no eye antibiotic had been prescribed nor had a bandage been applied.
  Patient visited GP cooperative with dog bite in hand. No antibiotics were administered.
Triage Patient called GP cooperative with pain in left side of abdomen. Patient had had diverticulitis before and asked for antibiotics. Patient received this medication prescription by telephone.
  Patient called GP cooperative with acute loss of hearing in one ear. Assistant told patient over the telephone that it was a cerumen impaction. Later, the patient got an urgent referral to an ear, nose, and throat specialist, and it turned out to be sudden deafness.
Diagnosis A 22-year-old patient presented herself at the GP cooperative with acute pain in the left thorax without fever. The GP heard chest crepitations and diagnosed the patient with pneumonia. The patient was treated with antibiotics. After six days, the patient visited her own GP because of persisting pain. The GP sent the patient out for an X-ray. The chest X-ray showed a pneumothorax, which could have been treated conservatively.
  A four-year-old patient visited the GP cooperative with a foot injury after being jammed between the spokes of her mother's bicycle. Her foot was blue, and she could not walk or stand on it. The GP did not perform a physical examination. Diagnosis: no fracture. Wait-and-see policy. Later the patient turned out to have epiphysiolysis.