Section A: Mistaken patient identity |
1. The wrong action is taken, or the right action is taken but for the wrong patient, for example, referral, clinical entry, prescription, acting on a test result, or drug administration. |
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Section B: Acts of omission |
2. An agreed referral is not made. |
3. Transport (ambulance) is not arranged while admitting a patient as an emergency. |
4. Discharging patients without advance notification of practice, district nurses, or making necessary arrangements. |
5. Not carrying out an agreed house visit. |
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Section C: Investigations |
6. An abnormal investigation result is not received by the practice that requested it. |
7. An abnormal test result is received by a practice but not considered for action, or the considered action is not performed. |
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Section D: Medication (prescribing, dispensing, administration, monitoring) |
8. The ‘wrong’ drug is prescribed, dispensed, or given. |
9. Drugs are prescribed at the request of non-practice clinicians and from other healthcare settings without clear, complete, and written requests. |
10. Prescribing medication when known, absolute contraindications exist: |
10a.Prescribing teratogenic drugs to a patient known to be pregnant. |
10b.Specific previous incidents, for example, combined oral contraceptive after previous confirmed DVT/PE. |
10c.Specific medical conditions (metformin, nitrofurantoin or NSAIDs in renal failure (or eGFR <30); beta-blockers for asthmatics; oestrogen only HRT for women with intact uterus). |
10d.Previous allergic reaction to the drug. |
11. Prescribing two drugs with known and potential serious interaction together. |
12. Prescribing or giving the wrong dose of medication. Specifically, prescribing doses higher than the maximum recommended in the BNF. |
13. Making changes to medication (dose, new, discontinue) without informing the patient or patient representative and documenting the change and rationale. |
14. Prescribing ‘high risk’ medication without ensuring adequate monitoring took place and results were satisfactory. |
15. Dispensing medication or providing a prescription to anyone other than the patient or patient representative. |
16. Giving the right drug via the wrong route or at the wrong site. |
17. Failure to reconcile medication after receiving hospital discharge documentation. |
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Section E: Medico-legal and ethical incidents |
18. Non-clinical team members should not perform clinical tasks. |
19. Physical assault of patients or healthcare workers. |
20. ‘Ignoring’ a patient’s living will. |
21. Breaching patient confidentiality. |
22. A practice team member works while intoxicated. |
23. ‘Losing’ controlled drugs. |
24. Accessing patient records for purposes other than delivery of care. |
25. Performing invasive or intimate procedures without offering a chaperone. |
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Section F: Clinical management |
26. Omission of certain, specific clinical actions in given scenarios are ‘never events’. |
26a.Prescribing repeated courses of antibiotics without a clinical assessment. |
26b. Not examining a febrile child. |
26c.Not obtaining and recording a blood pressure reading for patients presenting with acute-onset headache. |
26d.Not recording a peak-flow measure in patients with asthma presenting with an acute exacerbation. |
26e.Not referring a patient presenting with and treated for anaphylaxis to secondary care for observation. |
26f.Not referring a child suspected to have non-accidental injuries urgently. |
26g.Performing a speculum examination in patients >36/40 pregnant and presenting with PV bleeding. |
27. A patient suffers ‘severe burns’ from cryotherapy. |
28. Using non-sterile equipment. |
29. Performing a cervical smear without visualising the cervical os. |
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Section G: Practice systems |
30. A practice does not have an up-to-date and secure backup of their data. |
31. Medical waste and hazardous substances discarded in an inappropriate manner. |
32. If equipment is not in working order, maintained, available, or checked regularly. |
33. Inappropriate triage or refusal of access. |
34. Sending correspondence to a deceased patient. |
35. Patients should never be unsupervised (left alone) inside the practice. |
36. A death in the practice. |
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Section H: Teamwork and communication |
37. A new member of staff is not made aware of the known ‘high risk’ status of a patient before a consultation. |
38. Medical trainees are not provided with adequate supervision. |