Table 3 PAEs and interventions applied to reduce their incidence

Missing critical medical information required before procedure at the angiography unit.

Before the morning shift, nurses examined all cases of the day and called the relevant referring doctor to complete any missing information.

Medical staff from the angiography unit had meetings with the medical staff of the major referring departments in order to demonstrate the unit work and the importance of clear and complete medical information.

At the end of the procedure, not all patients received clinical instructions.

A special form was designed, in several prevalent, languages, which contained instructions for patients.

Instructions were given orally.

Typists of medical records made typing errors in diagnoses because doctors’ handwriting was not always clear.

Typists received lecture and guidance, and were instructed to call doctors in case of unclear handwriting.

Discontinuity in care at the MRI unit.

The MRI unit medical staff was lectured and given guidance regarding the importance of continuity in care and ways to maintain it.

A special form was designed, requiring written relevant medical information and signature on the document before leaving the shift.

Inappropriate use and storage of medical equipment and drugs.

A senior pharmacist examined all three units and formulated recommendations for appropriate storage of drugs and equipment.

Special color-coded stickers were designed in order to distinguish different drugs while performing the procedure.