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Table 4 Examples of detected patient safety incidents* judged to be preventable or potentially preventable

From: Applying the trigger review method after a brief educational intervention: potential for teaching and improving safety in GP specialty training?

Failure to initiate prophylactic treatment for or follow up a patient with gout resulted in a hospital admission
Patient with a significant drug allergy [prescribed the same medication] resulting in a further allergic reaction
‘Patient given inappropriate dosages of anti-diabetic medication with resultant renal injury’
‘Patient’s [misunderstanding] of warfarin dose led to increased requirement for monitoring’
‘Delayed diagnosis of ischaemic heart disease led to avoidable admission’
‘Lack of monitoring LFTs of a patient taking anti-fungal medication [resulted in] intensive follow-up’
Patient became symptomatically bradycardic as a result of a drug known to have this side effect and required review and medication adjustment
‘Change in medication with known side effects [may have] resulted in a fall and hospital admission’
Hospital admission for abdominal problem (overflow) due to incomplete assessment of patient by primary healthcare team
A delay in monitoring after an increased dosage of nephrotoxic medicine leading to a significant decrease in renal function – with increased monitoring requirements
Admission for transfusion from potentially avoidable delay in monitoring
Potential delayed diagnosis in symptomatic atrial fibrillation leading to hospital admission
  1. *Some incidents occurred more than once or were detected by more than one respondent. The original phrasing of some patient safety incidents were reworded to aid clarity.