2021_Book_TextbookOfPatientSafetyAndClin

17 Patient Safety in Internal Medicine
217
Table 17.1 (continued)
Phase Process Adverse event Contributing factors
Handover
Diagnostic or therapeutic omission or
delay
Unexpected death or clinical worsening
Unexperienced team
Inadequate skills
Lack of structured handover
Busy and noisy environment
Distraction, fatigue
Poor teamwork
Lack, inadequacy, or violation
of policy
Communication to
patient and/or
caregiver
Privacy failure
Communications provided to people not
authorized by the patient
Diagnostic or therapeutic omission or
delay due to poor or absent compliance
with care team indications or missed
information
Patient/caregiver dissatisfaction
Last day Discharge planning Canceled or delayed discharge
Lack of planning controls and follow-up
Early readmission for the same reason
Discharge
Discharge letter to the wrong patient
Incomplete discharge letter
Wrong or inappropriate discharge
destination
Unintentional drug discrepancies
Adverse drug reactions
Omitted or delayed diagnosis
communication
Omitted or delayed treatment
Inadequate non-technical skills
Lack or non-compliance with ad
hoc protocols
High workload
Lack of time
Poor teamwork
Misunderstanding
Patient cognitive impairment
Poor social support
Organizational failure (lack of
reference operators)
Poor teamwork
Poor decision-making
Patient/caregiver not engaged
Poor patient/caregiver education
Pressure to discharge
Poor social support
No anticipatory prescribing
Lack, inadequacy, or violation
of policy
See identification errors
Medical record not available,
illegible, not informative or
updated
Pending tests results
Busy and noisy environment
Distraction, fatigue
Pressure to discharge
Poor teamwork and
communication
Poor multidisciplinary
assessment
Poor medication reconciliation
Medications not available
Medical devices not available or
malfunctioning
No patient recall ongoing results
Poor patient/caregiver education
Lack, inadequacy, or violation
of policies
AEs in IM have been classified variously, e.g.
according to the clinical process or the nature of
disorder caused by AEs [7, 9] (see Tables 17.2
and 17.3). It is disappointing how the frequency
of certain AEs has worsened in decades:
healthcare- associated infections (HAIs) passed
from 9.5% in 1960 [1] to 21.4% in 2008 [10].
When you think about the potential most frequent
errors in IM, you probably think mainly
about medication and diagnostic errors since