Below are some examples of patient safety incidents with corresponding levels of harm.
Category of harm: no harm (impact prevented)
Definition: Any unexpected or unintended incident which was noticed and halted or reversed before it was able to cause harm to a patient.
A GP prescribes an inappropriate dose of a drug, which the local community pharmacist picks up when dispensing the prescription.
Category of harm: no harm (impact not prevented)
Definition: Any unexpected or unintended incident which did not lead to harm on this occasion.
A patient is on medication that requires blood pressure monitoring. The hospital discharge letter does not mention this to the GP, which results in the patient not being followed up appropriately. However, it is noted when the patient visits the GP for a further prescription. The patient’s observations are then found to be normal.
Category of harm: low
Definition: Any unexpected or unintended incident which required extra observation or minor treatment and caused minimal harm, to one or more persons.
A patient’s home visit is missed. The terminally ill patient required a pain assessment. This was picked up the following day, resulting in the patient continuing to be in pain until the medication was altered.
A patient trips and falls in the practice, resulting in a graze which requires a dressing.
Category of harm: moderate
Definition: Any unexpected or unintended incident which resulted in further treatment, possible surgical intervention, cancelling of treatment, or transfer to another area and which caused short-term harm, to one or more persons.
Continuing treatment with warfarin without monitoring clotting levels for a length of time which results in an overdose and bleeding problems that require close monitoring and follow-up.
Patient with external infusion line (e.g. Hickman line) gets an infection while at home following repeated disconnections, requiring a hospital admission for antibiotic therapy.
Category of harm: severe
Definition: Any unexpected or unintended incident that caused permanent or long-term harm to one or more persons.
The parents of a four-year old child contact the GP out of hours service with a history of recurrence of a high temperature following the onset of a presumed middle-ear infection five days ago. The child is four days into a course of oral antibiotics. There is no face-to-face consultation and it is suggested that the child contact their own GP in the morning.
On arrival at the practice the following morning the child is pale and subdued, has a raised respiratory rate, prolonged capillary refill time and tachycardia. The GP arranges immediate admission to hospital by ambulance where the child is diagnosed with sepsis and requires two days of high-dependency unit care before being transferred to the ward. After a further four days as an in-patient the child is discharged home with some permanent effects on hearing.
A patient who is a heavy smoker visits the GP with a cough. The patient’s name is Mr Jones. He has a chest x-ray and the report suggests a suspicious lesion with the advice to refer for further investigations. The GP writes on the report that an urgent appointment is needed and the receptionist files the report in Mr Jones’s file.
Mr Jones rings the practice for his results and the receptionist looks in his file and says that no report has been received yet and that the practice will ring him if there is any news in the next week. Mr Jones does not hear so assumes everything is ok. Two months later Mr Jones visits the GP on a routine appointment and Mr Jones’s urgent request is found. Mr Jones is referred and it is found that he has lung cancer.
Category of harm: death
Definition: Any unexpected or unintended incident which caused the death of one or more persons. The death must relate to the incident rather than to the natural course of the patient’s illness or underlying condition.
A patient suffering from chest pain is asked to wait for an available slot at the GP practice. As he feels difficulty in getting his breath, he goes for a walk, collapses and dies in the GP practice’s car park.
A practice receives a telephone call from a mother with a small child who seems unwell. The details are taken and a non-urgent note is left for the GP to give the mother a call at the end of surgery.
When the GP rings, the child is now quite ill with suggested meningitis symptoms. The GP immediately visits the child and gives antibiotics and arranges an emergency admission. However, the child collapses on route and is pronounced dead on arrival to hospital.