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Table 3 case descriptions of AEs

From: What are the safety risks for patients undergoing treatment by multiple specialties: a retrospective patient record review study

 

Case description

1

Admission recent myocardial infarction, heart failure, fever and suspected pneumonia in delirium patient with chronic renal insufficiency. Four specialties were involved during this admission (cardiology, geriatrics, internal medicine (main specialty), neurology). Confusion in nursing staff because different specialties (geriatrics and general internal medicine) did not discuss treatment policies and both communicated conflicting medications to the nursing staff, resulting in extra intervention and treatment for the patient. The reviewer scored the preventability as more than likely.

2

Admission with stomach ache and constipation. Four specialties were involved during this admission (general surgery (main specialty), gynaecology, intensivist, gastroenterology). CTscan showed ileus of the small intestine. Operation however followed ten days later resulting in unfavourable postoperative course. Communication with radiologist in an earlier stage could have led to a faster diagnosis. The reviewer scored the preventability as more than likely.

3

Admission for epileptic incident. Only one specialty was involved during this admission (neurology). Status epilepticus a month earlier, however after this previous admission no maintenance medication was given due to insufficient consultation internal medicine by neurologist. Adverse event was noticed during following admission. Reviewer scored the preventability as strong evidence of preventability.