Table 2 Type and number of significant events identified (191 SEA reports)

Disease diagnosis and disease management

(e.g. missed or delayed diagnosis of cancer, terminal care pain management)

Prescribing, dispensing and other drug issues

(e.g. wrong/inappropriate drug prescribed/administered, warfarin issue)

Patient and relatives

(e.g. patient behaviour, anger or upset)

Investigations and results

(e.g. incorrect results given to patient, results not acted upon)

Communication

(e.g. lack of communication, unsuccessful communication)

Administration

(e.g. complaint, breach of protocol)

Medical records and confidentiality

(e.g. breach of confidentiality, wrong records accessed)

Appointments and surgeries

(e.g. patient did not arrive issues, running late)

Home visits and external care

(e.g. delay in arrival, visit request not done)

Equipment

(e.g. computer search facility ineffective, difficulty accessing cupboard containing medical supplies)

Miscellaneous

(e.g. difficulty in signing death certificate, change in partnership personnel)

Health and safety

(e.g. staff injury, unsuccessful procedure for dealing with clinical waste)