Table 3

Incident typology

Incident type* N (%)Example
Documentation107 (41.4)Missing mammogram from previous year
Abnormal lab filed before MD had seen result
Lab report misfiled (two patients with same last name)
Medication77 (29.7)Prescribed synthroid, 75 μg instead of 100 μg
Prescribed Amoxil, pharmacy had penicillin allergy noted, EMR incorrect, did not list allergy
Wrong name written on prescription (was patient's sibling)
Clinical administration48 (18.7)Patient referred to paediatrician instead of podiatrist
Patient phone number in chart no longer in service
Referral to mental health never sent
Clinical process45 (17.5)Doing biopsy, didn't have container in room, specimen fell on floor
Pregnant patient missed important ultrasound, was not given appointment information
Patient needed Pap recall in 6 months, name was not put on recall list so was not notified
Resources6 (2.4)Bad news test result given over the phone to patient's family member
Medical device4 (1.6)Internet server down for 4 days, unable to get labs or process billings
Patient behaviour3 (1.2)Patient notified of abnormal results, did not show for appointment
Fall1 (0.4)Fall due to medication contraindication causing subdural haematoma
Infrastructure1 (0.4)Mouse spotted in office
No. of reports* 262
  • * Filtered for duplicates (two duplicated reports).

  • Multiple response set: reporters can select more than one response. Percentage is calculated over the number of reports not the number of selections, therefore totals ≠ 100%.

  • EMR, electronic medical record; Pap, Papanicolaou test.