| Acute Care | Mental Health |
---|---|---|
Exploration of possible causes | Vascular injury due to catheterization: brief exchange of viewpoints regarding complications of catheter manipulation | Missed information around food allergy: lack of communication between the nutrition department and the ward |
Consideration of systems problems | Cerebral infarction after Coronary Angiography (CAG): unclear lines of responsibility in the process of obtaining informed consent and describing the risk of complication deriving from CAG | Patient’s unplanned entry to electroconvulsive therapy: miscommunication between different units |
Critiquing of hypothesized causes | Very little discussion, with some exceptions | Not observed |
Seeking further information about the incident | Not much discussion, apart from questions as to subsequent actions made by a doctor involved in the case, and the relevant electronic medical records | Follow-up information requested for cases where the information about how incidents occurred was not complete |