Please categorise the Patient Safety Incident from the following choices

 

There are two steps to answering this question:

 

Step 1 – select the category (or type) of patient safety incident that you are reporting, there are 16 broad categories which are further subdivided into sub categories

 

Step 2 – select the sub category that most accurately describes the incident. For each sub category there is an "other" choice if the incident that you are reporting does not match any of the listed sub categories.

 

Examples

 

A patient who has been advised to wait to see the GP, but leaves before seeing the GP. Category = access, admission, transfer, discharge

Sub category = absconder / missing patient

 

A GP or practice nurse fails to act on signs and symptoms correctly, or fails to carry out the necessary examinations to elicit the signs.

Category = Clinical assessment

Sub category = diagnosis – Delay / failure

 

Giving confidential information such as smear test results inappropriately over the telephone to a patients husband without her permission.

Category = Consent, communication, confidentiality

Sub category = breach of patient confidentiality

 

A patient threatens physical violence against another patient in the reception waiting area and has to be restrained by two members of staff to prevent a physical attack.

Category = Disruptive, aggressive behaviour

Sub category = physical

 

A newly registered patient attends the surgery for an appointment with the GP but their notes / records have not been received by the new practice.

Category = Documentation

Sub category = documentation – no access to

 

Repeat retinal screening results for diabetic patient are scanned and filed in the patients records without review by the patients GP.

Category = implementation of care and ongoing monitoring

Sub category = test results / reports – failure / delay to interpret or act on

 

Inappropriate disposal of clinical waste, such as blood leaking from yellow clinical waste bags onto the floor or dirty needles not being disposed of correctly in the sharps bin.

Category = Infection control incident

Sub category = unsafe / inappropriate clinical environment

 

A patient suffering a minor burn on their leg after coming in contact with exposed pipes in the surgery waiting room.

Category = Infrastructure

Sub category = unsafe environment

 

A diabetic patient attends a routine diabetic check appointment with the practice nurse and reports feeling light headed and dizzy. The nurse wishes to check the patients' blood glucose level but is unable to do so as the surgery has run out of blood glucose monitoring strips.

Category = Medical device / equipment

Sub category = Lack of / unavailability of device / equipment

 

A patient returns to the surgery and explains that she has been given the wrong medicines on her repeat prescription. She has been prescribed Fluvoxamine tablets but she no longer takes these as her GP changed her medication to Fluoxetine capsules six months ago.

Category = Medication

Sub category = Prescribing

 

The full list of categories and sub categories are in the table below.

 

Category	Sub category
Access, Admission, transfer, discharge (including missing patient)	Absconder / missing patient Access / admission – delay / failure in access to hospital / care Access / admission – unexpected readmission /re-attendance Access / admission – unplanned admission / transfer to specialist care unit Discharge – delay / failure Discharge – inappropriate Discharge – planning failure Discharge – self or against medical advice Failure in referral process Transfer – delay / failure / inappropriate Transport – delay / failure Unsafe / inappropriate clinical environment (including clinical waste) Other
Clinical assessment (including diagnosis, scans, tests, assessments)	Assessment – lack of clinical or risk assessment Diagnosis – delay / failure to Diagnosis – wrong Inadequate handover of care Scans/ X-rays / specimens – inadequate / incomplete Scans / X-rays / specimens – mislabelled/ unlabelled Scans / X-rays / specimens – missing Scans / X-rays / specimens – wrong Test results / reports – failure / delay to interpret or act on Test results / reports – failure / delay to receive Test results / reports – incorrect Test results / reports – missing Tests – failure / delay to undertake Other
Consent, communication, confidentiality	Breach of patient confidentiality Communication failure – outside of immediate team Communication failure – with patient / parent / carer Communication failure – within team Failure to receive informed consent IT / telecommunications failure / overload Other
Disruptive, aggressive behaviour (includes patient to patient)	Physical Racial Sexual Verbal Other
Documentation (including electronic and paper records, identification and charts)	Appointment recording error Documentation – delay in obtaining healthcare record / card Documentation – healthcare / record card – mislabelled Documentation – missing / inadequate / wrong / illegible healthcare record / card Documentation – missing / inadequate / wrong / illegible referral letter Documentation – misfiled Documentation – no access to Patient incorrectly identified Test request form – none / incomplete Test results / reports – mislabelled Other
Implementation of care and ongoing monitoring / review	Delay / difficulty in obtaining clinical assistance Delay / failure in recognising complication of treatment Delay or failure to monitor Failure to follow up missed appointment Other
Infection control incident	Diagnosis – delay / failure to Diagnosis – wrong Failure of sterilisation or contamination of equipment Infection – cross / healthcare associated Infection – wound Test results / reports – failure / delay to interpret or act on Test results / reports – failure / delay to receive Test results / reports – missing Tests – failure / delay to undertake Treatment / procedure – delay / failure Treatment / procedure – inappropriate Unsafe / inappropriate clinical environment (including clinical waste) Other
Infrastructure (including staffing, facilities, environment)	Failure / delay in collection / delivery systems Inadequate check on equipment / supplies Lack of / delayed availability of beds (general) Lack of suitably trained / skilled staff Unsafe / inappropriate clinical environment (including clinical waste) Unsafe environment (light, temperature, noise, air quality) – personal safety Other
Medical device / equipment	Failure of device / equipment Lack / unavailability of device / equipment User error Wrong device / equipment used Other
Medication	Prescribing Preparation of medicines in all locations / dispensing in a pharmacy Administration / supply of a medicine from a clinical area Monitoring / follow up of medicine use Advice Supply or use of OTC medicine Other
Patient accident	Collision / contact with an object Contact with sharps (includes needle stick) Exposure to hazardous substance Exposure to cold / heat (includes fire) Inappropriate patient handling / positioning Slips, trips, falls Other
Self-harming behaviour	Self-harm Suspected suicide (actual) Suspected suicide (attempted) Other
Treatment, procedure	Delay / difficulty in obtaining clinical assistance Extended stay / episode of care Failure to discontinue treatment Inappropriate patient handling / positioning Infusion injury (extravasation) Missing needle / swab / instrument Retained needle / swab / instrument Treatment / procedure – delay / failure Treatment / procedure – inappropriate / wrong Treatment not clinically indicated Other
Maternal fetal neonatal incidents CNST triggers	Maternal death Undiagnosed breech Shoulder dystocia Post-partum Haemorrhage > 1500ml Eclampsia Venous thromboembolism Pulmonary embolism Third / fourth degree tears Stillbirth > 500g Neonatal death Birth trauma Neonatal seizures Term baby admitted to neonatal unit Other
Pressure ulcer	Acquired during NHS care
Other	Other