Examples of adverse events (AEs) and their causes and potential prevention strategies
| Description of AE | Main causal factors | Subcategories of T, H and O | Prevention strategies |
| Leaking undersized intravascular aortic stent, resulting in readmission and endovascular reintervention | Technical, human | Materials (TM), intervention (HRI) | Technology/equipment, training, procedures |
| Inadequate planning operation (ankle fracture) resulting in extended length of stay | Organisational | Management priorities (OM) | Procedures, motivation, staffing |
| Pneumonia after thoracotomy, requiring artificial respiration and treatment with antibiotics | Other | – | – (not preventable) |
| (Blood) infusion rate too high in patient known with heart failure and gastrointestinal bleeding, resulting in respiratory insufficiency and contributing to death | Human | Knowledge (HKK), qualification (HRQ), verification (HRV) | Evaluation |
| Not-indicated surgery of adrenal gland (lung metastases) resulting in needless suffering, respiratory insufficiency and early death | Human, organisational | Knowledge (HKK), coordination (HRC), knowledge transfer (OK) | Procedures, information and communication, evaluation |
| Persistent haemorrhage of wound feeding probe | Patient related | – | – (not preventable) |
| Missed diagnosis pulmonary embolism, contributing to death | Human | Knowledge (HKK), violation (V) | Training, procedures, quality assurance/peer review |
| Lens remains left behind after lens extraction, requiring resurgery | Human | Intervention (HRI) | Training, quality assurance/peer review |
*For explanation of causal factors, see table 1.