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Table 2 Stage one 2016 examples (subset of 21 observations analysed 13 incorrect codes)

From: Developing Healthcare Team Observations for Patient Safety (HTOPS): senior medical students capture everyday clinical moments

Code theme Description Error or Threat Student correct in E or T Number
Infection • Consultant not washing hands between patients T Incorrect 1
• Failure of medical staff to change uniform/dress is a threat to other patients T Correct 1
Insufficient skills • Operation where staff had not recognised the drill setting before starting T Incorrect 1
Wrong patient • Similar patient’s consultant confuses the patients corrected by Registrar T Incorrect 1
Privacy and dignity • Curtain not fully pulled around patient during a ward round T Incorrect 1
• Sensitive information spoken loudly at the ward desk T Incorrect 1
Slow computers • Issues with slow computers T Correct 1
Technology • No dicta-phone available T Correct 1
Layout design • Layout design of clinic T Correct 1
Equipment • Needed help to identify the right equipment before surgery—pieces missing T Incorrect 1
Guidelines not followed • Changing uniform/clinical dress in isolation wards between seeing different patients E Undefined 1
Poor professionalism • Management of discharge—varicose veins T Incorrect 1
Confidentiality and Patient-centred care • Junior doctor dictating notes with door open T Incorrect 1
Checking • Patient who was not sent his operation date—took a year—administrative error T Incorrect 1
Systems issues • Transferring data from paper to IT prescribing T Correct 1
• The white board was not up dated at handover T Incorrect 1
• Bed shortages and problems with transfer of patient back to ward from ITU T Correct 1
Team communication • Junior doctor not prepared for the ward round and had to go back and gather more data T Incorrect 1
• Nurse joining a ward/team meetings out of sequence with which patient is being discussed and wrong information given corrected by consultant T Correct 1
Excluded data wrongly included neither error or threat
 Error or Threat Issues raised
  T Recorded as slow computers, whereas the installation of dictate software by a new clinician is a normal process. If we had had a chat as a team, this understanding about a normal processes could have been relayed.
  E Transfer of patient to the ward during the night from ITU is normal practice and within hospital protocol
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Pilot and Feasibility Studies

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