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Table 2 Types of adverse events

From: Prevalence and consequences of patient safety incidents in general practice in the Netherlands: a retrospective medical record review study

Examples of adverse event type

Number (%)

Organisation

 

• wrong form was sent with a PAP smear so it could not be evaluated

116 (55.0)

• referral letter was not ready when promised

 

• 24 hour blood pressure measurement agreed upon but not performed

 

Treatment

 

• Patient uses three kinds of antihistaminics

31 (14.7)

• AB prescribed although patient is allergic

 

• Too low doses of PPI had been prescribed

 

Communication

 

• Patient was not told that lab test should be performed on an empty stomach, so had to be repeated

26 (12.3)

• Patient was told to inhale salbutamol (a pulmonary β2 adrenergic receptor agonist) prior to the long function test

 

• GP agreed to call the patient but forgot

 

Diagnosis

 

• Recurrent urine infection in a male, without further diagnostics

 

• Patient exercise induces shoulder pain, which is considered musculoskeletal; no further research is done; five days later patient is admitted to hospital with a myocardial infarction

21 (10.0)

• Lab result interpreted incorrectly

 

Prevention

 

• No action on elevated cholesterol in a patient with multiple vascular risk factors

14 (6.6)

• A fasting glucose test was agreed upon, but not performed

 

• Administration of NSAID without gastric protection in an elderly patient

 

Triage

 

• A patient calls with a high fever and pyelonephritis complaints. A home-visit is planned for the next day

3 (1.4)