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Table 1 Incidents that occurred during the process of care

From: A system analysis of a suboptimal surgical experience

Step in process Department Incident Outcome
Preoperative assessment Surgery/Urology Failure to warn or notify patient to stop gabapentin* Hemorrhage, purpura (after surgery)
Surgery Surgery/Urology Failure to stop bleeding Hemorrhage, swelling, pain, worry
   Failure to install drains Swelling, pain
Post-operative process Emergency Failure to be seen by physician Delay, swelling, pain, worry
   Failure to call urology resident Delay in being seen
   Failure to triage and to recognize ongoing bleeding Near syncope
  Surgery/Urology Lack of beds Waiting without supervision (risky for many reasons)
  Emergency, Surgery/Urology Inexperienced residents recommending overly conservative "watch and wait" Continued swelling, purpura, pain, worry
   Attending not seeing patient Expert assessment not provided
Second preoperative assessment Surgery/Urology Released without being seen Expert assessment not provided
Second surgery Anesthesia Failure to warn or notify patient to stop gabapentin Longer recovery
  Surgery/Urology Inexpert IV insertion Hemorrhage, purpura (in arm)
   Long wait for surgery Swelling, pain, worry
  1. *Note that gabapentin can increase vasodilation and purpura in 1% of patients. The health system of interest appropriately asks patients at multiple points in the process of care as to what medications they take; however, there was never a suggestion that the patient should stop taking this drug.