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Table 2 Description, nature and known potential underlying causes for the missed AEs after review stage 2

From: Is detection of adverse events affected by record review methodology? an evaluation of the “Harvard Medical Practice Study” method and the “Global Trigger Tool”

Missed AEs by the HMPS method Rejected as AE Severity scalea Criteria numberb Orthopaedic knowledge Computerised record system knowledge Time limit 20 minutes
Pressure ulcer   1 3    NA
Pain   1 1    NA
Infiltrated intravenous infusion   1 3    NA
Pressure ulcer   1 3    NA
Missed AEs by the GTT Rejected as AE Severity Scale c Triggers C13 procedure” and/or C14 care: other” Orthopaedic knowledge Computerised record system knowledge Time limit 20 minutes
Re-fracture   G   X   X
Urinary retention   E X    
Neurological harm   E X X X  
Wound infection   F    X  
Wound infection   E    X  
Pulmonary embolism   F     
Infiltrated intravenous infusion   E X    
Infiltrated intravenous infusion   E X    
Urinary retention   E X    
Wound infection   F    X  
Urinary retention   E X    
Discharge deficiencies   F     
Urinary tract infection   F X    
Urinary retention   E X    
Urinary retention   E X    
Thrombophlebitis   E X    
Pressure ulcer   E     
Late detection of fracture   F X    
Mistreated fracture   F X X   
Wound during dressing   E X    X
Urinary retention X      
External fixation, wound   E X    X
Red skin from bandage   E X    
Fungus   E     
Pressure ulcer   E     
Urinary retention   E X    
Infiltrated intravenous infusion   E X    
Ad latus displaced fracture X      
Sensory loss   E X X   
Overdose of drug   F X    
Heparin induced thrombocytopenia   E X    X
Rash due to bandage   E X    
Pressure ulcer   E     
Pressure ulcer   E     
Wound infection   E     
Rash due to drug   E X    
Bleeding during surgery X      
Increased liver enzymes X      
Subsidence of the femoral stem X      
Wrong operation performed initially   F     
Urinary retention   E X    
Neurological harm   G X X   
Bleeding when urinary catheter is removed   E X    X
  1. AE, adverse events; HMPS, “Harvard Medical Practice Study”; GTT,” Global Trigger Tool”; NA, Not Applicable for this method.
  2. a 1, minimal impairment, recovery within 1 month.
  3. b 1, the index admission was an unplanned admission related to previous healthcare management within 30 days; 3, hospital-incurred patient injury.
  4. c E, contributed to or resulted in temporary harm to the patient and required intervention; F, contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalisation; G, Contributed to or caused permanent patient harm.