Examples of preventable adverse events identified during hospitalisation
| Case no. | Clinical description | Preventability score* |
|---|---|---|
| 1 = virtually no evidence for preventability; 2 = slight to modest evidence; 3 = preventability not quite likely; 4 = preventability more likely than not; 5 = strong evidence; 6 = virtually certain evidence. | ||
| 1 | Inhalation pneumopathy during anaesthetic induction for oesophageal diverticulum in a 48-year-old man | 4 |
| 2 | Pneumothorax in a 51-year-old man hospitalised for pneumonectomy (aspergillosis on tubercular sequelae) occurring during subclavian catheterisation | 5 |
| 3 | Stomach lesion during nephrectomy via coelioscopy, requiring subsequent open surgery in a 59-year-old woman | 4 |
| 4 | Perforation of the colon during colonoscopy in a 73-year-old man | 4 |
| 5 | Dissatisfaction expressed by a 57-year-old patient hospitalised for endoscopic retrograde cholangiopancreatography under general anaesthetic, which was delayed on account of a leak in the endoscope discovered once the patient had been anaesthetised | 6 |
| 6 | A 79-year-old patient dissatisfied after discharge was delayed; patient hospitalised for spontaneous haematoma of the left intracranial haemorrhage, waited 25 days for a control scan which was never actually performed. Communication problem between the admitting and radiology departments | 4 |
| 7 | Lumbar pain in connection with second lumbar vertebra fracture not diagnosed in emergency unit, delay in diagnosis and corset fitted in a 20-year-old man | 4 |
| 8 | A 96-year-old woman hospitalised for acute sigmoiditis and varicose ulcer treatment had intense systematic pain during care procedures despite preventive treatment (15 mg morphine administered subcutaneously) | 4 |