Examples of diagnostic errors and other adverse events identified in the study
| Case history | Type of error | Dimension of care | Anticipated harm and duration |
| Patient with known alcohol abuse presented with inability to walk. History of leg pain and past immobilisation was missed. Patient experienced pulmonary embolism. | Diagnostic error | Patient–provider encounter | Severe Temporary |
| Patient presented with hip pain after a recent fall. Also, patient experienced chest pain and shortness of breath for 1 week. Early signs of infection (leucocytosis, cough with coffee-ground sputum) were missed. 3 days later patient developed septic shock and died 2 days later. | Diagnostic error | Patient–provider encounter | Death Permanent |
| Patient is admitted with multiple rib fractures. Chest X-ray on admission showed a haemothorax, which was missed. 2 days later, patient developed sudden shortness of breath and RRT is called. Repeat chest X-ray confirmed the haemothorax. | Diagnostic error | Follow-up and tracking | Severe Temporary |
| Patient presented with altered mental status. During initial assessment history of alcohol use was missed. Patient developed alcohol-withdrawal hallucinations and seizures 2 days later. | Diagnostic error | Patient–provider encounter | Severe Temporary |
| 2 patients had allergic reactions/anaphylaxis to CT contrast agent. | Adverse drug reaction | NA | Mild Temporary |
| Patient was accidentally given multiple hypotensive agents (dose of prazosin was increased and amlodipine was also prescribed). Patient suddenly became hypotensive. | Adverse drug reaction | NA | Mild Temporary |
RRT, rapid response team.