Cases and variants (from Weiner et al,9 reprinted with permission)*
| Case presentation | Biomedical red flag | Contextual red flag | Criteria for medical error for each variant | ||
| Baseline error | Biomedical error | Contextual error | |||
| Man, aged 43 years, with recent persistent asthma symptoms despite being prescribed a low dose of a high-cost, brand-name, inhaled glucocorticoid | “Sometimes I wake up wheezing or coughing at night” | “Things have been tough since I lost my job” | No intervention to address inadequately controlled asthma symptoms | Not treated for gastro-oesophageal reflux despite four symptoms of the condition | Patient advised to increase dosage of current medications without consideration of cost, despite four indications that he cannot afford them |
| Woman, aged 47 years, presenting for preoperative assessment of hip replacement, reports mild hypertension and overweight | Mentions recent weight gain, constipation, and heavy menses | “I'm looking forward to the surgery so I can take better care of my son” | No discussion of possible risk factors of surgery | Patient not evaluated or treated for hypothyroidism despite four symptoms of the condition | Physician raises no concerns about surgery despite patient's first priority being to care for an adult child who has end-stage muscular dystrophy and depends on her fully |
| Man, aged 59 years with diabetes, presents with two presyncopal episodes after previous doctor increased insulin dosage | “Felt some pounding in my chest when it happened” | Confuses dosages and says, “It's hard for me to keep numbers straight” | No adjustment of insulin dosing or discussion of changes in diet to prevent hypoglycaemia | No ECG, event monitor, or stress test ordered, or β blocker prescribed in patient with four symptoms of arrhythmia | No discussion of or plan to address obstacles to self-care in patient with four indications of learning or cognitive disability that impairs his capacity to correctly dose his medication since he left a community where he had assistance |
| Man, aged 72 years, with unexplained weight loss | Shows signs of being depressed | Seems impoverished and possibly homeless | No evaluation for cancer in patient with unexplained weight loss, and depression and malnutrition ruled out | No treatment or referral for depression in patient with four symptoms of depression | No discussion of or plan to address malnutrition in patient who provides four indications of inadequate access to food |
↵* Case presentations with criteria for defining errors.