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Table 1 Clinical scenarios used in the survey

From: What do family physicians consider an error? A comparison of definitions and physician perception

Name

Scenario

Mr. Black/LFT

Dr. Jones ordered liver function tests to evaluate Mr. Black's health complaints. The next day, a report of Mr. Black's lipids (but not liver tests) shows up on Dr. Jones' desk and they are normal. Dr. Jones documents "normal lipids, notify patient" and sends it to his nurse. A week later, Mr. Black returns, more ill, and is found to have acute hepatitis A.

Mrs. Rose/glucose

Mrs. Rose, a patient with high blood pressure, has a basic metabolic profile performed, and is found to have a random blood glucose of 189. Dr. Smith documents "have patient return for repeat glucose and glycohemoglobin." The nurse documents "attempted phone call, no answer." Eight months later, the patient returns with a yeast infection and is found to have a random blood glucose of 356

Ms Brown/TSH

Dr. Miller reviewed a large number of lab results from his "normal lab results" folder and sent them to be filed. The next month, he sees Ms Brown again for menstrual irregularities. In reviewing her chart, Dr. Miller sees he wrote "normal, file" next to an elevated TSH of 37.

Mr. White/broken tube

Mr. White got his blood drawn by Dr. Jones' medical assistant for an ordered test. After he left, she dropped the tube and broke it. Mr. White is called, and makes another visit to the office to get his blood drawn the next day.

Ms Green/CT results

Ms Green wants to know the results of head CT scan ordered by her doctor to evaluate her headaches. The test was done at the hospital X-ray department last week. She calls the office and leaves a message asking the doctor or nurse to call her. When no one returns her call, she calls back two days later and makes an appointment. At the visit, the CT results are not in her chart, and cannot be found in the office.