Table 1.

Unique Events Associated With Preventable Harms (N = 221), by Taxonomy Order

Number of Unique Reports
Unique Events1st2nd3rd
Note: taxonomy is ordered from general to specific. Coding actually went to a fourth order of specificity; 3 orders are shown.
1. Access breakdown63
    1.1. Difficulty initiating contact with office by telephone10
    1.2. Excessive delay in obtaining appointment with clinician10
    1.3. Excessive delay in obtaining referral to specialist1
    1.4. Excessive delay in / no return of telephone call7
    1.5. Excessive office waiting time17
    1.6. Service not covered11
    1.6.1. Medications not covered2
    1.6.2. Family member excluded from practice1
    1.6.3. Specialty services limited8
    1.7. Service not available7
    1.7.1. Lack of telephone care4
    1.7.2. Lack of acute care2
    1.7.3. Lack of evaluation before referral1
2. Communication breakdown17
    2.1. Within office8
    2.1.1. Insurance information not recorded1
    2.1.2. Insurance information not updated1
    2.1.3. Payment not posted1
    2.1.4. Appointment improperly scheduled3
    2.1.5. Wrong chart used for patient2
    2.2. Between office and outside entity other than patient9
    2.2.1. Referrals not done4
    2.2.2. Improper coding of service1
    2.2.3. Medication refill not called to pharmacy2
    2.2.4. Records not transferred to requesting clinician2
3. Relationship breakdown82
    3.1. Inadequate time with clinician9
    3.2. Intermediary imposed on communication with clinician6
    3.3. Care by other than usual clinician4
    3.4. Disrespect or insensitivity63
    3.4.1. Evident in interpersonal communication38
    3.4.2. Evident in patient flow in office20
    3.4.3. Evident in office environment5
4. Technical error54
    4.1. Deficiency in history4
    4.1.1. Incomplete history of present illness2
    4.1.2. Incomplete history of medications1
    4.1.3. Incomplete past history1
    4.2. Deficiency in physical examination1
    4.2.1. Incomplete physical examination1
    4.3. Deficiency in investigations1
    4.3.1. Artifact introduced in x-ray1
    4.4. Deficiency in diagnosis11
    4.4.1. Failure to appreciate severity/acuity of problem1
    4.4.2. Wrong diagnosis4
    4.4.3. Dismissing selected symptoms2
    4.4.3. Perceived failure to make any diagnosis4
    4.5. Deficiency in treatment and follow up35
    4.5.1. Poor injection technique1
    4.5.2. Results of investigations not shared with patient6
    4.5.3. Inadequate patient education reprocedure, diagnosis or treatment18
    4.5.4. Premature recommendation for hysterectomy1
    4.5.5. Perceived polypharmacy1
    4.5.6. Wrong medication dose2
    4.5.7. No treatment for pain2
    4.5.8. Inadequate follow up care4
    4.6. Deficiency in business practice2
    4.6.1. Requiring patient to pay before insurance company1
    4.6.2. Balance billing by participating clinician1
5. Inefficiency of care5
    5.1. Excessive data elements for registration1
    5.2. Duplicative registration2
    5.3. Unnecessary office visit2