Item | Examples of patient safety incidents (in the ESPRIT study) |
---|---|
ENVIRONMENTAL FACTORS | |
Patient’s social context | Elderly, suffering from dementia, unsuitable assistance plan |
Background of care | |
Unplanned consultation | A woman took an appointment just for herself and came with her son |
Place of care | Incomplete medical examination because the patient was seen at home |
Workload management | Workload increased by adding too many consultations |
Disruptive element | Phone call caused the physician to dismiss his patient |
Health system | |
Healthcare service | A medical specialist was required but unavailable on weekends |
Financial or administrative issue | No general practitioner declared to social security |
HUMAN FACTORS | |
Linked to the patient | Aggressive patient (who felt rejected by her physician) |
Linked to the provider | Stressed physician (bad news needed to be announced) |
Linked to other providers | Pharmacist distracted when dispensing treatment |
Linked to a third party | Indiscretion of the mother of a patient regarding her daughter |
TECHNICAL FACTORS | |
Equipment | |
Failure, malfunction, unavailability | Failure of the computer server |
Incorrect use | Wound following the inappropriate use of pedicure equipment |
Information system | |
Incorrect or missing data | Lack of discharge letter after hospitalization of a patient |
Failure of the communication system | Ultrasound result was unreadable over the internet |
PROCESS OF CARE | |
Cognitive dimension | |
Lack of initial training | Ignorance of drug contraindication |
Incorrect recall (after training) | Insufficient exploration of thromboembolic risk |
Wrong synthesis | Minimization of a chronic kidney disease |
Care procedure | |
Inappropriate or unachieved procedure | Coronary patient who stopped the statin on her own |
Lack of protocol | Medical appointment for an emergency assigned too late by the secretary |
Care coordination | |
Communication failure | The nurse did not call the physician despite an unusual dosage |
Lack of (or incorrect) monitoring | Lack of specialized ophthalmic monitoring despite serious uveitis |
Lack of response after feedback | Diabetes mellitus non-equilibrated, without medical appointment, for several months despite several blood tests |