Table 2 Stage one 2016 examples (subset of 21 observations analysed 13 incorrect codes)

Infection

• Consultant not washing hands between patients

T

Incorrect

1

• Failure of medical staff to change uniform/dress is a threat to other patients

T

Correct

1

Insufficient skills

• Operation where staff had not recognised the drill setting before starting

T

Incorrect

1

Wrong patient

• Similar patient’s consultant confuses the patients corrected by Registrar

T

Incorrect

1

Privacy and dignity

• Curtain not fully pulled around patient during a ward round

T

Incorrect

1

• Sensitive information spoken loudly at the ward desk

T

Incorrect

1

Slow computers

• Issues with slow computers

T

Correct

1

Technology

• No dicta-phone available

T

Correct

1

Layout design

• Layout design of clinic

T

Correct

1

Equipment

• Needed help to identify the right equipment before surgery—pieces missing

T

Incorrect

1

Guidelines not followed

• Changing uniform/clinical dress in isolation wards between seeing different patients

E

Undefined

1

Poor professionalism

• Management of discharge—varicose veins

T

Incorrect

1

Confidentiality and Patient-centred care

• Junior doctor dictating notes with door open

T

Incorrect

1

Checking

• Patient who was not sent his operation date—took a year—administrative error

T

Incorrect

1

Systems issues

• Transferring data from paper to IT prescribing

T

Correct

1

• The white board was not up dated at handover

T

Incorrect

1

• Bed shortages and problems with transfer of patient back to ward from ITU

T

Correct

1

Team communication

• Junior doctor not prepared for the ward round and had to go back and gather more data

T

Incorrect

1

• Nurse joining a ward/team meetings out of sequence with which patient is being discussed and wrong information given corrected by consultant

T

Correct

1

 Error or Threat

  T

  E