Death occurring in practice premises | 0 | 0 | – |
|
New cancer diagnosis | 32 | 1 | Delayed diagnosis of rectal carcinoma |
|
Death where terminal care took place at home | 15 | 1 | Possibly an avoidable death from malignant melanoma |
|
Patient complaint | 17 | 0 | – |
|
Suicide | 3 | 1 | Suicide of patient referred urgently to mental health team |
|
Section under Mental Health Act | 8 | 1 | Violent psychotic patient absconded from section on ward |
|
Other administrative | 95 | 2 | Delayed diagnosis of ectopic due to unlabelled sample |
| | | New diabetic moves away before diagnosis given |
|
Prescribing-related events | 46 | 4 | Gastrointestinal (GI) bleed from warfarin and Cox II drug reaction |
| | | Incorrect phenytoin dose prescription |
| | | The wrong dose of warfarin dispensed |
| | | Two different hospitals gave contra-indicated drugs to one patient leading to GI bleed |
|
Nursing-related events | 23 | 3 | Failure to act urgently in new diagnosis of diabetic child |
| | | Unwitting duplication of oral hypoglycaemic drugs in nursing home |
| | | Failure to hydrate a patient with dementia in nursing home |
|
Other medical | 70 | 8 | Refusal of readmission when aneurysm patient deteriorated |
| | | Absent emergency drugs in surgery |
| | | Inappropriate management of chest pain |
| | | Missed diabetes diagnosis in a child |
| | | Anti-depressant overdose |
| | | Unprepared for childhood immunisation anaphylaxis |
| | | Emergency oxygen unavailable |
| | | Discharge of dying patient without notification to GP or family |
|
Other | 28 | 1 | Assault on GP |
|
Total | 337 | 22 | – |