1 | Inpatient suicide | ‘Information from the contact person was found in the nursing chart but not in the medical chart. (…) The contact person was not informed when the patient was offered leave.’ |
2 | Unexpected cardiac arrest | ‘During the procedure, the patient becomes increasingly broncospastic. The nurse asks both doctors several times to withdraw the scope (…) but gets no response.’ |
3 | Call for help to patient in distress | ‘The technician paged the resident. The resident never returned the call. The technician went for help in the corridor but found no one there. (…) The [other] nurse thought the patient in distress was a patient waiting in the corridor.’ |
4 | Low stock of intravenous fluids | ‘Because the message about the product being out of stock and new supplies not delivered was verbal (…) the risk of the product being out of stock was increased.’ |
5 | Inpatient suicide | ‘The patient was transferred from closed to open psychiatric unit which increased the risk of continuity problems (…) The written information was comprehensive and did not describe the staff members concerns about the patients' suicidal risk.’ |
6 | Unexpected cardiac arrest | ‘At sign-out on the fifth day after admission, it was not made clear that the condition had deteriorated during the night shift. The patient saturated [insufficiently] and was in respiratory distress (…) The sedative treatment was continued.’ |
7 | Unexpected death | ‘The way the nurse verbally communicated that the patient needed to be seen, made the physician think it could wait.’ |
8 | Medication error | ‘The treatment plan [for this specific condition] was usually made during morning rounds. The [lab] result was not available until later that day. The night-nurse saw the result and called the resident, but no decision was made and the patient did not receive [this specific] treatment.’ |
9 | Unexpected cardiac arrest | ‘A patient arrives to the ER after intake of [a high number of] tablets. Normal procedure is that all patients with poisonings are seen by an anaesthetist. The anaesthetist was occupied by another acute procedure. During telephone conversation between the ER nurse and the anaesthetist it was not made clear that the dose was lethal. The patient was transferred to the general medical ward and the anaesthetist expected to be paged if the patient needed further attention.’ |
10 | Patient suicide during furlough | ‘If the verbal and written communication between the districts had been sufficient, the medication would most likely not have been delayed and cancelled.’ |
11 | Inpatient suicide | ‘After every [of the numerous] operation[s] the young patient was discharged to the shelter. (…) There was no contact between [staff at] the unit and [staff at] the shelter.’ |
12 | Unexpected cardiac arrest | ‘[There was] no communication between doctors on duty. (…) No one carried the prescribed tests for anaemia out. (…) There was no joint treatment plan. (…) No one saw the test report as it was sent to another unit.’ |
13 | Wrong-site anaesthesia | ‘The senior doctor was not in the room during the patient identification process. (…) The two doctors [did] not communicate about the site.’ |
14 | Unexpected cardiac arrest | ‘The diagnostic procedure was ordered “when opportunity arises.” (…) The diagnosis dragged on because of communication errors between the units’ |
15 | Unexpected cardiac arrest | ‘…this [information] was not heard by the physician. (…) Information was lost, and the involved physicians did not have precise agreements. (…) The team lacked a joint unequivocal plan for the procedure.’ |
16 | Death after elective operation | ‘The surgeon's handover was too brief. (…) The chart note was too brief to assess the patient's status. (…) There was no consensus in the team about the procedure. (…) Coordination of the procedure relies on good communication. This was absent in this case.’ |
17 | Inpatient suicide | ‘Because of busyness in the receiving unit there is no verbal communication during handover regarding the patient's status.’ |
18 | Lack of anaesthetic during procedure | ‘Because there was no clear-cut communication at the beginning of the procedure (…), the risk of misunderstandings was increased.’ |
19 | Delayed treatment | ‘The communication between [doctor A] and [doctor B] was not optimal. This induced insecurity about the (…) treatment. (…) [Doctor A] misunderstood the purpose of the call.’ |
20 | Delayed treatment | ‘The resident assumed that the patient would be transferred and did therefore not inform the internist about the patient in the ward’ |
21 | Delayed treatment | ‘The diagnosis was not described sufficiently in the chart and called for verbal explanation. (…) A combination of work load and communication errors caused the patient to wait for hours before admittance.’ |
22 | Delayed treatment | ‘There were no uniform guidelines for nurse–doctor communication after a patient fall. (…) This can result in delayed treatment.’ |
23 | Delayed treatment | ‘Because of problems with overcrowding, the patient was transferred from one unit to another after admittance (…) but the doctor at [the new] unit was not informed (…) The patient was not mentioned at sign-out as it was expected that the patient could be discharged (…) and (for the same reason) a specialty was not decided for the patient (…) The patient was not registered in the electronic system.’ |
24 | Postoperative cardiac arrest | ‘The doctors in the team did not agree on the diagnosis, the severity of the condition or the plan.’ |
25 | Delayed treatment | ‘There was no clear-cut communication path to make sure the decisions from the two medical teams (…) were communicated and documented in all instances and at all times. (…) The decision was only recorded in the nursing record and communicated verbally to the doctor.’ |
26 | Failure during oxygen therapy | ‘The nurse thought the doctor heard the message, but wasn't sure.’ |
27 | Medication error | ‘The doctor and the nurse used different criteria for evaluating the condition.’ |
28 | Delayed treatment | ‘The on call-doctor did not find it necessary to see the patient even after several telephone consultations with the intern.’ |
29 | Medication error | ‘The factor 10 insulin overdose was not communicated to the doctor on duty (…) as the insulin was not considered a potent drug.’ |
30 | Medication error | ‘The room was sealed [to reduce risk of infection] and staff therefore had to rely on telephone communication. (…) The nurse and the inexperienced doctor did therefore not ask a senior colleague for help when in doubt about the right dose.’ |
31 | Cancelled operation after anaesthesia | ‘To save time (to catch up on the operation programme) the anaesthesiologist started the anaesthesia before the surgeon was present to re-evaluate the indication.’ |
32 | Error during preadmission evaluation | ‘The information about the patient provided by the ambulance staff left the receiving doctor with the impression that the patient wasn't critically ill.’ |
33 | Delayed treatment | ‘Because there were no established procedures for communication between the two units, the x-ray report was not discussed.’ |
34 | Suicide during leave | ‘During readmission the patient was admitted to another unit. (…) By admitting the patient to a different unit, there is a risk of loss of information between the two staff groups. (…) The doctor at the second unit was unaware of this specific information.’ |
35 | Complications after use of medical device | ‘Because there were no procedures or communicative pathways for discussion of routines or quality and safety, the risks of initiating or continuing potentially hazardous treatments were increased.’ |
36 | Complications during CPR | ‘[When the alarm sounded] approximately 15 people showed up in the relatively small room. For some of the staff members present it was unclear who was in charge of the resuscitation. (…) There were five doctors present (…) However this did not lead to any discussion of who was in charge.’ |
37 | Delayed treatment | ‘The involved parties did not know who was responsible for the procedure. New team members were thus not informed about the [important clinical information]. (…) If communication about trauma patients isn't systematic and there is no apparent team leader, the risk of loss of valuable information is increased and diagnosis can be delayed.’ |
38 | Suicide during leave | ‘When transferring patients to lower levels of care, there is a risk of loss of relevant information and downplay of symptoms. (…) During the meeting the nurse expressed concern for the patient and the transfer. This concern was not documented in the chart.’ |
39 | EMR-recovery error | ‘The dispatcher could not call all the users. (…) If communication routines are established after a pilot test with few users and not from a test including the full number of users, the risk of establishing insufficient communication pathways is imminent.’ |
40 | Complications to treatment | ‘The condition was not immediately recognised, as there was no systematic communication or documentation of information regarding the problem.’ |
41 | Postoperative complications | ‘The [procedure] was ordered electronically but not executed before the patient died as there was no communication between the ordering doctor and the radiologist. The procedure could therefore not be completed as an urgent case.’ |
42 | Failure to resuscitate | ‘The nurse aid was late for the briefing and did not hear that [she/he] was the contact person for the patient. (…) The patient was thus not observed until lunch time’ |
43 | Errors during preadmission evaluation and transfer | ‘Several professionals were involved [in the transfer]. This increased the risk of no final decision being made. It was furthermore unclear who the team leader was during trauma-handling. This increased the risk of internal and external misunderstandings of information.’ |
44 | Delayed diagnosis | ‘[During telephone communication] the doctor got the impression that the patient could be transferred to and admitted at the [other] hospital. [This was not the case].’ |