Table 3 Reasons for occurrence of significant events and the number of reports identifying these occurrences (191 SEA reports)

Individual health care professional 'errors'

(e.g. lack of knowledge of practice/hospital protocols, poor clinical task delivery)

Communication

(e.g. substandard communication between practice and patient, substandard communication between practice and hospital/out of hours/other agencies)

Patient and relatives

(e.g. negative patient behaviour, illness behaviour)

Disease/diagnosis/management

(e.g. difficult diagnosis, incomplete history/examination)

Administration

(e.g. poor task delivery, ineffective administrative system/protocol)

Medication

(e.g. error writing/prescribing/administering (wrong drug dosage/formulation prescribed), no system/protocol to check for out of date emergency tray/bag medicines)

Tests/investigations/results

(e.g. no sample tracking/record, delay in checking blood tests results)

Patient records

(e.g. failure to check notes adequately, failure to record in notes)

Equipment

(e.g. ineffective emergency buzzer system for staff to identify location of emergency, inadequate search facility on computer system)

General practice protocols/systems/guidelines

(e.g. no formal protocol for checking BHCGs, no system for emergency bag tracking)

Clinical behaviour (e.g. doctor avoidance of addressing a difficult situation, lack of clinical leadership of patient review)

Reasons for event undetermined

Appointments

(e.g. delay in being seen, not enough time with patients)

Visits/external care

(e.g. change in out of hrs service, delay in attending house visit)