TableĀ 3

Opportunities for improvement as classified by the corporate mortality-review committee

Opportunity for improvementNumber of occurrences N=97
Goals of care were not discussed or the discussion was inadequate25
Delay in diagnosis or failure to achieve a diagnosis8
Uncontrolled pain7
Inappropriate delay in transfer to hospice or long-term care7
Developed a pressure ulcer in hospital5
Did not receive a treatment that was indicated5
Appropriate specialists were not involved in the patient's care5
Fall in hospital4
Delay in surgery that affected patient's outcome and contributed to death4
Hospital-acquired infection3
Had multiple ER visits leading to admission and did not receive appropriate treatment3
Complications of a procedure2
Admission to hospital was unnecessary. There was no care given in hospital that the patient was not already receiving at their place of residence2
Inadequate assessment and consideration of preoperative risk2
Inadequate monitoring of an unstable patient2
Error made during surgery2