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Table 4 Specific examples of errors relating to seven of the key subject areas

From: Exploring patterns of error in acute care using framework analysis

  Description of error ( scenario number in parentheses ) Evidence from scenario (S) or debrief (D) GEMS classification
Hospital systems
1 Surgeon paged (but had not answered) and junior doctors assumed that the surgeon was therefore on his/her way to the ward (2) Junior (S): “He’s been called so he’s on his way.” Rule-based mistake
2 Patient with major post-operative bleeding is causing concern but no attempt made to obtain senior help (17) Junior (D): “I was thinking about maybe calling the anaesthetist. I was thinking: I need an anaesthetist, where do I get one of those?’ Knowledge-based mistake
Prioritisation
3 Specific investigation (electrocardiogram [ECG]) is arranged before any assessment of the patient has been undertaken (3) Junior (S): “What we need to do first is another trace of the heart.” Rule-based mistake
4 One junior doctor is very keen to call for senior help but dissuaded from doing so by other junior who insists on the requirement for investigation results prior to calling (9) Junior (S): “Should we get an SHO [more senior doctor] here?” Reply from other junior: “I suppose we need to send the bloods first, and get an ECG [electrocardiogram].” Submission error
Procedural skills
5 Nurse corrects lead placement of junior doctor for ECG monitor (6) Nurse (S): “The red one goes on the other side.” Junior: “Oops, so it does.” Skill-based slip/ lapse
6 Recognition of severe sepsis but no attempts made to give antibiotics (18) Tutor (D):“Did the patient get antibiotics?” Junior: “No, because I didn’t know how to administer them Knowledge-based mistake
Situation awareness
7 Junior doctor suggested checking the volume of blood in the patient’s drains, but the task was never undertaken (12) Junior (D): “I remember you saying ‘have you checked the drains?’ because we hadn’t.” Other junior doctor: “but then I didn’t actually myself look at the drains when I should have, I thought you had, yeah, I thought… Skill-based slip / lapse
8 Junior doctor tells senior colleague on the phone that a 12 lead ECG has been performed when it has not, it had merely been mentioned to the nurse Junior (D): “When she was asking me what tests we had done and for information on what we’d done, you know, we seemed to have covered all the bases. Compound error
Treatment
9 Patient in septic shock with no evidence of cardiac dysfunction treated with 500mls of saline over one hour (3) Junior (S): “I don’t want to put him into heart failure, let’s put it over an hour.” [discussing intravenous fluid prescription with nurse] Rule-based mistake
Communication
10 During phone call, surgical registrar [more senior doctor] is dismissive of junior doctor, who is told to ‘just carry on’ but left with the false impression that the senior doctor was coming to help (5) Junior (D): “I felt better because they [the surgical registrar] were coming to see the patient.....if I had been completely useless in my handover then they probably would have just said for me to do all these tests and then ring back… Skill-based slip/ lapse
Ethical principles in practice
11 Junior doctors persuaded by hypoxic, confused, exsanguinating patient to remove the oxygen mask (9) Junior (D): “I didn’t know how much you can make someone do something who is, you know, confused. But then he’s sick. That was hard.” Rule-based mistake