Table 5

Types of problems in care that contribute to patient death (More than one option may apply for each patient).

Type of problem in care (%)Preventable deaths n=52Non-preventable deaths n=79
Clinical Monitoring*40 (31.3)25 (18.0)
Diagnosis38 (29.7)30 (21.6)
Drug or fluid related27 (21.1)30 (21.6)
Technical problem§8 (6.3)26 (18.7)
Infection related9 (7.0)22 (15.8)
Resuscitation0 (0)3 (2.2)
Other6 (4.7)3 (2.2)
  • * Failure to act upon results of tests or clinical findings, set up monitoring systems or respond to such systems or increase intensity of care when required.

  • Missed, delayed or inappropriate diagnosis as a result of failure to perform an adequate assessment of patient's overall condition including appropriate tests or lack of focused assessment when required.

  • Side effects, inappropriate use, failure to give prophylactic care, anaphylaxis, etc.

  • § Related to an operation or procedure whether on ward, in a diagnostic suite or in theatre and including inappropriate or unnecessary procedures.