Opportunities for improvement as classified by the corporate mortality-review committee
| Opportunity for improvement | Number of occurrences N=97 |
|---|---|
| Goals of care were not discussed or the discussion was inadequate | 25 |
| Delay in diagnosis or failure to achieve a diagnosis | 8 |
| Uncontrolled pain | 7 |
| Inappropriate delay in transfer to hospice or long-term care | 7 |
| Developed a pressure ulcer in hospital | 5 |
| Did not receive a treatment that was indicated | 5 |
| Appropriate specialists were not involved in the patient's care | 5 |
| Fall in hospital | 4 |
| Delay in surgery that affected patient's outcome and contributed to death | 4 |
| Hospital-acquired infection | 3 |
| Had multiple ER visits leading to admission and did not receive appropriate treatment | 3 |
| Complications of a procedure | 2 |
| Admission to hospital was unnecessary. There was no care given in hospital that the patient was not already receiving at their place of residence | 2 |
| Inadequate assessment and consideration of preoperative risk | 2 |
| Inadequate monitoring of an unstable patient | 2 |
| Error made during surgery | 2 |
| Other | 11 |