Table 4 Selection of reported incidents
From: Effects on incident reporting after educating residents in patient safety: a controlled study
Discipline | Description of incident | Causes mentioned |
|---|---|---|
Internal medicine | Unnecessarily high glucose level. | - Notification by supporting personnel was too late (attending resident was supposed to be called by telephone about this) - Very busy at department |
Multiple | Preventable infections. | - Health care workers do not always wash their hands before touching another patient - Laziness - Time pressure - Unaware of seriousness of the consequences |
Gynecology | Delayed delivery of a child in foetal need. | - Suction pump out of order (probably caused by bump to door pillar) - Health care worker's ignorance of slurp sounds made by suction pump - Insufficient checking of the suction pump |
Revalidation | Needle (with cover) found in bed with patient. | - Incompetent laboratory assistant - Patient also had not noticed the needle - Very busy at department |
Emergency medicine | Patient needed plaster bandage, but was sent home without. | - Miscommunication between physician and nurse - Nurse followed own policy |
Pediatrics | Patient needed isolated room, but was admitted to a room with multiple beds. The other beds in the room were kept empty. | - There were no isolated rooms available - It was late in the evening |
Anesthesia | Unknown amount of local anesthetic was given to patient during spinal anesthesia. | - Hastiness - Connection between spinal needle and sprayer was insufficient and fell apart |
Orthopedics | Decubitus ulcer. | - Decubitus prevention plan not followed by nurses - Busy nightshift |
General surgery | Patient was kept sober all day and was prepared for the operation room, but the operation was not performed that day. | - Operation was not registered on operating list - Unclear description in patient's chart - Unclear treatment policy - Order was not checked - Miscommunication between health care workers |