Table 2 Examples of cases with and without adverse events and preventability

An 80-year-old man presented with a myocardial infarction with three hours of chest pain. He was treated promptly with streptokinase, heparin and aspirin. On day 3 he had further chest pain, with new ECG changes, and he died 12 hours later of cardiogenic shock.

Adverse event (no preventability) [11]

A 50-year old woman underwent coronary angiography for unstable angina. During the angiogram she sustained an anaphylactic reaction to the contrast, with cardiac arrest. She was able to be resuscitated promptly, without permanent sequelae, and hospitalisation was prolonged by 10 days. Evidence for prior contrast reactions was sought and not found.

Adverse event (no preventability) [1]

Abdominal pain and fever following elective surgical procedure. Patient readmitted for antibiotic treatment.

Adverse events (low preventable) [25]

Young right handed man sustained a fracture of the radius within the wrist joint. It required operative reduction, K-wire fraction and bone grafting. At the 10-day check the position had shifted and re-operation was required. The end result was very good.

Adverse event (high preventability) [11]

A 67-year old woman underwent a laparoscopic cholecystectomy, which proceeded to an open operation. Endoscopic retrograde cholangiopancreatography was undertaken eight days after the operation to remove a gallstone in the common bile duct; cannulation was not possible and the procedure was aborted. Ten days after the operation the patient collapsed and died suddenly. Autopsy findings showed extensive deep venous thrombosis and saddle pulmonary embolus. There was no documented evidence of thromboembolic prophylaxis in the medical record.

Adverse event (high preventability) [1]

Admission because of severe anaemia. The anaemia had been documented in previous admission but not investigated fully, which resulted in delayed diagnosis of colorectal carcinoma.