Unique Events Associated With Preventable Harms (N = 221), by Taxonomy Order
| Number of Unique Reports | |||
|---|---|---|---|
| Unique Events | 1st | 2nd | 3rd |
| Note: taxonomy is ordered from general to specific. Coding actually went to a fourth order of specificity; 3 orders are shown. | |||
| 1. Access breakdown | 63 | ||
| 1.1. Difficulty initiating contact with office by telephone | 10 | ||
| 1.2. Excessive delay in obtaining appointment with clinician | 10 | ||
| 1.3. Excessive delay in obtaining referral to specialist | 1 | ||
| 1.4. Excessive delay in / no return of telephone call | 7 | ||
| 1.5. Excessive office waiting time | 17 | ||
| 1.6. Service not covered | 11 | ||
| 1.6.1. Medications not covered | 2 | ||
| 1.6.2. Family member excluded from practice | 1 | ||
| 1.6.3. Specialty services limited | 8 | ||
| 1.7. Service not available | 7 | ||
| 1.7.1. Lack of telephone care | 4 | ||
| 1.7.2. Lack of acute care | 2 | ||
| 1.7.3. Lack of evaluation before referral | 1 | ||
| 2. Communication breakdown | 17 | ||
| 2.1. Within office | 8 | ||
| 2.1.1. Insurance information not recorded | 1 | ||
| 2.1.2. Insurance information not updated | 1 | ||
| 2.1.3. Payment not posted | 1 | ||
| 2.1.4. Appointment improperly scheduled | 3 | ||
| 2.1.5. Wrong chart used for patient | 2 | ||
| 2.2. Between office and outside entity other than patient | 9 | ||
| 2.2.1. Referrals not done | 4 | ||
| 2.2.2. Improper coding of service | 1 | ||
| 2.2.3. Medication refill not called to pharmacy | 2 | ||
| 2.2.4. Records not transferred to requesting clinician | 2 | ||
| 3. Relationship breakdown | 82 | ||
| 3.1. Inadequate time with clinician | 9 | ||
| 3.2. Intermediary imposed on communication with clinician | 6 | ||
| 3.3. Care by other than usual clinician | 4 | ||
| 3.4. Disrespect or insensitivity | 63 | ||
| 3.4.1. Evident in interpersonal communication | 38 | ||
| 3.4.2. Evident in patient flow in office | 20 | ||
| 3.4.3. Evident in office environment | 5 | ||
| 4. Technical error | 54 | ||
| 4.1. Deficiency in history | 4 | ||
| 4.1.1. Incomplete history of present illness | 2 | ||
| 4.1.2. Incomplete history of medications | 1 | ||
| 4.1.3. Incomplete past history | 1 | ||
| 4.2. Deficiency in physical examination | 1 | ||
| 4.2.1. Incomplete physical examination | 1 | ||
| 4.3. Deficiency in investigations | 1 | ||
| 4.3.1. Artifact introduced in x-ray | 1 | ||
| 4.4. Deficiency in diagnosis | 11 | ||
| 4.4.1. Failure to appreciate severity/acuity of problem | 1 | ||
| 4.4.2. Wrong diagnosis | 4 | ||
| 4.4.3. Dismissing selected symptoms | 2 | ||
| 4.4.3. Perceived failure to make any diagnosis | 4 | ||
| 4.5. Deficiency in treatment and follow up | 35 | ||
| 4.5.1. Poor injection technique | 1 | ||
| 4.5.2. Results of investigations not shared with patient | 6 | ||
| 4.5.3. Inadequate patient education reprocedure, diagnosis or treatment | 18 | ||
| 4.5.4. Premature recommendation for hysterectomy | 1 | ||
| 4.5.5. Perceived polypharmacy | 1 | ||
| 4.5.6. Wrong medication dose | 2 | ||
| 4.5.7. No treatment for pain | 2 | ||
| 4.5.8. Inadequate follow up care | 4 | ||
| 4.6. Deficiency in business practice | 2 | ||
| 4.6.1. Requiring patient to pay before insurance company | 1 | ||
| 4.6.2. Balance billing by participating clinician | 1 | ||
| 5. Inefficiency of care | 5 | ||
| 5.1. Excessive data elements for registration | 1 | ||
| 5.2. Duplicative registration | 2 | ||
| 5.3. Unnecessary office visit | 2 | ||