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Table 2 Frequency of categories of avoidability with definitions and examples

From: Identifying ‘avoidable harm’ in family practice: a RAND/UCLA Appropriateness Method consensus study

Rating Category of avoidability No. scenarios Definition Examples
1 Totally unavoidable n = 18 Family Practice professionals have adhered to all appropriate evidence-based guidelines or best practice at the level of the health care professional (e.g. knowledge or skill errors) and / or the practice (e.g. administrative processes). There is no absolute causation between the identified error(s) and the harm outcome. Family practice could have done no more. A patient on methotrexate receives evidence-based blood test monitoring. An urgent blood test is undertaken when there is a suspicion about immune-compromise underlying a presentation with a chest infection. Patient is advised to withhold methotrexate whilst taking antibiotics. Despite the FPs efforts to treat the infection, and worsening advice provided, the patient is admitted to hospital following deterioration with sepsis.
A 55-year old man presented with an acute MI. He was an asylum seeker and had not as yet registered with a FP.
2–3 Probably unavoidable n = 13 Family Practice professionals have adhered to appropriate evidence-based guidelines or best practice at the level of the health care professional (e.g. knowledge or skill errors) and / or the practice (e.g. administrative processes). There is considerable doubt concerning absolute causation between the identified error(s) and the harm outcome and if family practice could have done more. A patient attends with a tonsillar lesion and is prescribed antibiotics and advised to return in 2 weeks for review. The patient did not return for 4 weeks, at which point the FP deemed an urgent referral to ENT was indicated and an inoperable squamous cell carcinoma was diagnosed.
A patient with a 12-month history of atrial fibrillation presents with an ischemic stroke. The patient has been prescribed anticoagulation, and INR has been in the target range for 90% of the time over the previous 6 months.
4–6 Possibly avoidable n = 10 Family Practice professionals have adhered to all appropriate evidence-based guidelines and / or the practice (e.g. administrative processes). There is some doubt concerning absolute causation between the identified error(s) and the harm outcome. It is unclear whether the event would have been avoidable with more input from family practice. A patient with diabetes is the main carer for his wife with dementia. He has declined a specialist referral for retinal screening in the past for this reason. He presents with sudden onset blindness due to a retinal detachment on a background of diabetic retinopathy.
A patient is admitted to hospital with an upper gastrointestinal bleed. The patient is 45 years old with a history of coronary heart disease on regular aspirin therapy.
7–8 Probably avoidable n = 53 ‘Probably avoidable’ was judged by the same criterion as possibly avoidable although there is less doubt concerning absolute causation between the identified error(s) and the harm. The outcome may not have occurred with more family practice intervention. A patient on methotrexate that has not had the recommended blood monitoring is admitted to hospital with a pneumonia and a low blood white cell count.
A patient aged 50 is diagnosed with Bladder Cancer. The patient had presented with symptoms of frequency and pain and despite not having any bacterial growth on several MSUs, had red blood cells 5–99 on each one. The FP seeing her did not realize the relevance of this finding and referred her as a routine referral and not less than 2-week wait. She had metastatic disease after an 18 week wait.
9 Totally avoidable n = 1 Outcome experienced by the patient is directly attributed to the demonstrable failure in family practice to adhere to evidence-based or best practice at the level of the health care professional (e.g. knowledge or skill errors) and / or the practice
There is a clear and absolute causation between the identified error(s) and the harm outcome. The harm would not have occurred with more family practice intervention. Family practice should have done more.
Prescribing a non-steroidal anti-inflammatory drug (NSAID) to a patient also taking Warfarin which resulted in an upper gastrointestinal bleed.