50 / 66
48
7.9.1 Areas of clinical incidents
Table 8: Severity of criticism of perceived clinical management issues.
Less severe
Most severe
Areas of clinical incidents
None detected Consideration
Concern
Adverse event
Outcome of incidents
N/A
Did not affect clinical outcome May have contributed to death Probably contributed to death
Preventable incidents
N/A
Probably not
Probably
Definitely
Association of incidents
N/A
Hospital
Clinical team
Surgical team
Table 9: Frequency of clinical management issues during the audited period.
Degree of criticism of patient management
Total occurrences
(n=8,431 in 6,179 cases)
Patients affected by
clinical issues (n=6,179 (%))
No issues identified
4,046
4,046 (65.4%)
Area of consideration
2,636
1,221 (19.8%)
Area of concern
1,202
561 (9.1%)
Area of adverse event
480
330 (5.3%)
Missing data
67
21 (0.4%)
Total
8,431
6,179 (100%)
Perceived impact on patient outcome
Total occurrences
(n=8,431 in 6,179 cases)
Patients affected by
clinical issues (n=6,179)
No issues of management identified
4,046
4,046 (65.4%)
Did not affect clinical outcome
1,000
489 (7.9%)
May have contributed to death
2,748
1,251 (20.2%)
Probably contributed to death
403
316 (5.1%)
Missing data
234
77 (1.3%)
Total
8,431
6,179 (100%)
Perceived preventability of clinical issues
Total occurrences
(n=8,431 in 6,179 cases)
Patients affected by
Clinical issues (n=6,179)
No issues identified
4,046
4,046 (65.4%)
Definitely preventable
533
379 (6.1%)
Probably preventable
1,723
795 (12.9%)
Probably not preventable
1,494
732 (11.8%)
Definitely not preventable
163
96 (1.6%)
Missing data
472
131 (2.2%)
Total
8,431
6,179 (100%)
Clinical team* responsible for management issue
Total occurrences
(n=8,967 in 6,179 cases)
Patients affected by
clinical issues (n=6,179)
No issues identified
4,046
4,046 (65.4%)
Surgical team
2,081
1,152 (18.6%)
Other clinical team
1,033
309 (5.0%)
Hospital issue
279
64 (1.1%)
Other factors*
257
64 (1.1%)
Missing data
1,271
544 (8.8%)
Total
8,967
6,179 (100%)
Audit period 1 July 2007 to 30 June 2015.
*Other factors can include issues such as staffing levels, patient transfer, patient refusal, ambulance care, anaesthetic care and availability or quality of critical care support.
* More than one clinical team can be responsible for a management issue.
7.5%
Event probably contributed to death
2007-2014
5.1%
Event probably contributed to death
2014-2015