TableĀ 3

Errors in five dimensions

Dimensions of 35 error casesn (%*)
Patient Related5 (14.3)
Delay in seeking care0 (0.0)
Lack of adherence to appointments0 (0.0)
Other (patient refused admission on initial visit; did not fill outpatient medications; changed the history (story) several times; asked to leave prior to complete work-up, rushing diagnosis; did not provide correct contact information for follow-up)5 (14.3)
Patientā€“provider encounter24 (68.6)
Problems with history14 (40.0)
Problems with physical examination2 (5.7)
Failure to review previous documentation4 (11.4)
Problems ordering diagnostic tests for further work-up17 (48.6)
Other: unnecessary procedure performed1 (2.9)
Diagnostic tests11 (31.4)
Ordered test, not performed at all0 (0.0)
Ordered tests, not performed correctly0 (0.0)
Ordered tests, not interpreted correctly9 (25.7)
Misidentification0 (0.0)
Other: attending over-read of preliminary radiology result3 (8.6)
Follow-up and tracking26 (74.3)
Problems with follow-up of abnormal diagnostic test results23 (65.7)
Problems with scheduling of appropriate and/or timely follow-up visits6 (17.1)
Other: failure to prescribe antibiotics for diagnosed infection1 (2.9)
Referrals4 (11.4)
Problem initiating referral2 (5.7)
Lack of appropriate actions on requested consultation1 (2.9)
Communication breakdown from consultant to referring provider1 (2.9)
Other0 (0.0)
  • *Each case may have several contributing factors involved. Dimensions and items within each dimension are not mutually exclusive.