Errors in General Practice

Medical errors in general practice usually arise from a combination of patient complexity, clinical uncertainty, time pressure, communication failures, medication risk, recall-system weaknesses, and broader practice governance issues. A strong clinical response should focus on both immediate patient safety and system improvement, rather than blame alone.

Open disclosure is an essential part of managing adverse events. It involves open, honest and timely communication with the patient, family or carer when harm or potential harm has occurred. It includes acknowledging the event, saying sorry or expressing regret, explaining known facts, avoiding speculation or blame, supporting the patient and staff, investigating what happened, and implementing changes to reduce recurrence.

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Key Definitions

Term	Meaning in General Practice	Example
Medical error	Failure in planning or execution of care. May or may not cause harm.	Wrong dose prescribed but identified before patient takes it.
Near miss	Error that could have caused harm but was prevented or did not reach the patient.	Abnormal potassium result filed but later detected before harm occurred.
Adverse event	Patient harm associated with healthcare rather than the underlying disease.	Delayed cancer diagnosis due to missed follow-up of abnormal imaging.
Sentinel / serious adverse event	Significant harm, death, or major risk requiring urgent escalation, disclosure and system review.	Missed critical result causing severe deterioration.
Recall failure	Failure to communicate, action, track or complete follow-up of a clinically significant result or review need.	Abnormal Hb, PSA, cervical screening, FIT, imaging or renal function result not conveyed promptly.
Open disclosure	Open discussion with a patient/family/carer after an adverse event.	Apologising for a delayed abnormal result, explaining known facts, arranging care and reviewing the system.

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Common Types of Errors in General Practice

Category	Examples
Diagnostic error / delay	Missed ACS, stroke/TIA, cancer, sepsis, ectopic pregnancy, meningitis, temporal arteritis.
Medication error	Wrong drug, dose, frequency, interaction, allergy, renal dosing error, monitoring failure.
Investigation / recall failure	Test not ordered, test not completed, abnormal result not reviewed, patient not contacted, follow-up not tracked.
Referral failure	Urgent referral sent as routine, referral not received, no confirmation of appointment, long wait not escalated.
Communication failure	Poor handover, unclear safety-netting, incomplete discharge follow-up, language barrier.
Procedural complication	Infection, bleeding, vasovagal episode, retained suture, failed follow-up after procedure.
Immunisation error	Wrong vaccine, wrong interval, expired vaccine, cold-chain breach.
Documentation error	Wrong patient file, incomplete medication list, missing allergies, unclear plan.
Confidentiality breach	Email, fax, SMS or result sent to wrong recipient.
Safeguarding failure	Missed family violence, child protection concern, elder abuse, suicide risk.

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Why Errors Occur: Contributing Factors

Patient Factors

Factor	Examples
Multimorbidity	Diabetes, CKD, heart failure, COPD, frailty, polypharmacy.
Atypical presentations	Elderly patients, children, pregnancy, immunosuppression.
Communication barriers	Low health literacy, language barrier, hearing impairment, cognitive impairment.
Access barriers	Cost, transport, homelessness, unstable phone access, fear, cultural barriers.
Non-attendance / non-response	Missed appointments, did not answer calls, voicemail full.
Assumption of “no news is good news”	Patient assumes results are normal if not contacted.
Fragmented care	Multiple specialists, hospital discharge, RACF, allied health, locum care.

Practitioner Factors

Factor	Examples
Cognitive bias	Anchoring, premature closure, confirmation bias, diagnostic momentum.
Time pressure	Short appointments, multiple issues, running late, interruptions.
Incomplete history/examination	Missed red flags, medication history, allergy status, pregnancy status.
Failure to reassess	Repeatedly treating as “viral”, “musculoskeletal” or “anxiety” without review.
Result not reviewed promptly	GP inbox backlog, GP leave, competing urgent tasks.
Abnormality not recognised	Trend missed, mild but significant abnormality overlooked.
Poor safety-netting	Patient not told what deterioration looks like or when to re-present.
Fatigue / cognitive overload	High workload, after-hours result review, emotional stress.
Poor documentation	No clear plan, no responsibility assigned, no timeframe recorded.

System Factors — Most Important for Exam Answers

Factor	Examples
Weak recall system	No reliable tracking of abnormal results until completed.
No mandatory “result actioned” workflow	Result marked as seen but no documented action.
Poor delegation clarity	Admin unsure whether to phone, SMS, book appointment or escalate.
No escalation pathway	No policy for non-response to abnormal or urgent results.
IT limitations	No dashboard for outstanding results, weak alerts, accidental filing.
GP leave cover failure	Results not reassigned when requesting doctor is away.
No audit process	Practice does not routinely check missed abnormal results.
No incident register	Near misses not captured or reviewed.
Poor induction	New GP, nurse or reception staff unaware of local recall protocols.
Lack of clinical governance	No regular review of incidents, complaints or adverse outcomes.

Environmental Factors

Factor	Examples
High workload	Large result inbox, urgent same-day issues, overbooked clinics.
Staffing shortages	Inadequate reception, nursing or admin support.
Interruptions	Phone calls, walk-ins, emergencies, competing tasks.
Poor team communication	GP expects phone call; admin sends SMS only; no confirmation loop.
Fragmented interface with hospitals	Delayed discharge summaries, unclear responsibility for follow-up.

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Recall Failure: Delayed Communication of Abnormal Result

Example Scenario

A patient had an abnormal investigation result, but there was a delay in conveying the result and arranging appropriate follow-up.

Potential Consequences

Consequence	Example
Delayed diagnosis	Cancer, diabetes, renal impairment, infection, anaemia.
Delayed treatment	Antibiotics, anticoagulation, urgent imaging, specialist referral.
Clinical deterioration	Sepsis, electrolyte disturbance, bleeding, organ damage.
Psychological harm	Distress, loss of trust, anger, complaint.
Medico-legal risk	Complaint, negligence claim, AHPRA notification.
System failure identified	Recall process found to be unreliable.

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Factors Contributing to Recall Failure

Patient Factors

• Incorrect or outdated mobile number, address or email.
• Did not respond to phone calls, SMS or letters.
• Voicemail full or phone disconnected.
• Low health literacy.
• Language or communication barrier.
• Unstable housing or poor access to phone/internet.
• Assumed “no news is good news.”
• Did not understand importance of follow-up.

Practitioner Factors

• Result not reviewed promptly.
• Abnormality not recognised as clinically significant.
• Trend not reviewed.
• No clear follow-up plan documented.
• No timeframe documented.
• Over-reliance on the patient to arrange review.
• Cognitive overload, fatigue, interruptions.
• Poor safety-netting at time of ordering test.

System Factors

• No robust recall system.
• Result could be filed without action being documented.
• No outstanding abnormal-result dashboard.
• No clear distinction between routine, abnormal, urgent and critical results.
• Poor delegation between GP, nurse and admin.
• No escalation policy for failed contact.
• No backup process when GP is away.
• IT alerts inadequate or ignored.
• No audit of abnormal results.
• No near-miss or incident register.

Environmental Factors

• Busy practice.
• Large volume of pathology and imaging results.
• Staff shortages.
• Poor communication between reception, nurses and doctors.
• Multiple clinicians involved.
• Hospital, specialist or pathology communication delays.

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Swiss Cheese Model

The Swiss cheese model explains how adverse events occur when multiple layers of safety fail at the same time.

Each defensive layer has “holes” or weaknesses. Harm occurs when the holes align, allowing the error to pass through all safeguards and reach the patient.

Safety Layer	Hole / Weakness
Patient details	Phone number outdated.
GP review	Result viewed but action not clearly documented.
Admin recall	Admin unsure how urgently to contact patient.
IT system	No alert for unresolved abnormal result.
Escalation pathway	No registered letter or emergency contact process after failed calls.
Audit	No routine check of unclosed abnormal results.

Clinical Interpretation

Concept	Meaning
Active error	The abnormal result was not communicated promptly.
Latent system failure	The practice did not have a reliable recall and escalation system.
Defensive layers failed	GP review, admin recall, IT alerts and audit did not prevent the delay.
Main learning point	Focus should be on system improvement, not blame alone.

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Immediate Management After an Error or Adverse Event

Step 1 — Make the Patient Safe

The first priority is clinical safety.

Action	Examples
Assess current clinical risk	Is the patient unstable, septic, bleeding, suicidal, deteriorating?
Provide immediate treatment	Cease incorrect medication, treat adverse effect, arrange monitoring.
Escalate if needed	Ambulance, ED referral, urgent specialist advice.
Stop ongoing harm	Correct dose, update allergy, recall affected patients.
Arrange follow-up	Same day, next day, phone review, repeat pathology/imaging.

For recall failure, the immediate priority is to:

• Contact the patient urgently.
• Assess current clinical status.
• Explain the abnormal result.
• Arrange appropriate clinical follow-up.
• Escalate to ED/specialist care if clinically indicated.
• Document all actions and communication.

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Step 2 — Open Disclosure

https://www.safetyandquality.gov.au/sites/default/files/resources/attachments/open-disclosure-principles-elements-and-process_9.pdf

Open disclosure should occur when an adverse event has caused harm, may have caused harm, or has caused significant distress or loss of trust. It should be timely, honest, empathetic, factual and documented.

Open disclosure may require more than one conversation, especially if all facts are not yet known.

Core Principles of Open Disclosure

Principle	Meaning in Practice
Open and timely communication	Speak with the patient/family as soon as practicable. Provide updates as more facts become available.
Acknowledgement	Acknowledge that something went wrong. Do not minimise or delay communication.
Apology or expression of regret	Say sorry for what happened and for the harm or distress caused.
Factual explanation	Explain known facts clearly. Avoid speculation.
No blame	Do not blame individuals or make statements beyond the known facts.
Support patient/family/carer	Allow questions, acknowledge distress, offer practical and emotional support.
Support staff	Deencouraging incident reporting providing training in open disclosure offering debriefing and emotional support avoiding a blame culture
System improvement	Link the event to incident review, practice change and audit. The aim is to understand: – what happened – why it happened – what system factors contributed – what changes are required to reduce recurrence
Confidentiality	Maintain patient and clinician confidentiality. Document professionally.

Suggested Wording

Component	Example
Acknowledge	“There has been a delay in communicating this abnormal result to you.”
Apologise	“I’m sorry this occurred.”
Explain known facts	“The result was received on this date and should have been followed up earlier.”
Avoid speculation	“We are reviewing exactly how this happened before giving you a final explanation.”
Explain clinical significance	“This result means we need to organise…”
Explain next steps	“I have arranged repeat bloods / imaging / ED review / urgent referral.”
Prevention	“We will review our recall process to reduce the chance of this happening again.”
Support	“You are welcome to bring a family member or support person to our next discussion.”

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Steps in the Open Disclosure Process

1. Detect and Assess the Incident

Immediate actions:

• Identify the adverse event or near miss.
• Assess severity of harm.
• Provide prompt clinical care to prevent further harm.
• Notify relevant clinicians or senior staff.
• Preserve privacy and confidentiality.
• Support staff involved.

2. Signal the Need for Open Disclosure

Early communication should include:

• Acknowledgement of the event.
• Apology or expression of regret.
• Explanation that further review may be needed.
• Arrangement of time/place for further discussion if required.
• Identification of a practice contact person.
• Avoidance of blame or speculation.

3. Prepare for the Discussion

Before a formal meeting:

• Gather known facts.
• Review the clinical record.
• Clarify who should attend.
• Appoint a lead clinician.
• Consider whether family/carers should be present.
• Prepare a clear factual explanation.
• Identify support options.
• Plan documentation.

4. Conduct the Discussion

Include:

• Introductions and roles of attendees.
• Apology or expression of regret.
• Factual explanation of what is known.
• Opportunity for patient/family to describe their perspective.
• Opportunity for questions.
• Discussion of personal impact.
• Agreed plan for follow-up care.
• Explanation of investigation/review process.
• Reassurance that findings and system changes will be communicated.

5. Provide Follow-Up

Follow-up should include:

• Ongoing clinical care.
• Updates about review findings.
• Explanation of changes made to reduce recurrence.
• Opportunity for further questions.
• Referral to another clinician if the patient wants another opinion.

6. Complete the Process

At completion:

• Provide final verbal and/or written communication where appropriate.
• Document investigation findings.
• Communicate outcomes to relevant clinicians.
• Record agreed follow-up care.
• Document any system improvements.

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What to Avoid Saying

Avoid:

• “It was not my fault.”
• “The receptionist made a mistake.”
• “This definitely caused your harm.”
• “Nothing serious happened.”
• “These things happen.”
• “We are liable.”
• “You should have followed this up yourself.”

Better phrasing:

• “I am sorry this happened.”
• “At this stage, these are the facts we know.”
• “We are reviewing how this occurred.”
• “We will let you know what we find and what changes we make.”
• “Our priority now is your care and safety.”

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Step 3 — Documentation

Document in a factual, neutral and contemporaneous way.

Area	What to Record
Event facts	Date, time, what happened, who identified it.
Result details	Test, date requested, date received, abnormal finding.
Delay	When the delay was recognised and likely timeframe.
Clinical effect	Symptoms, harm, risk, examination findings.
Immediate action	Treatment, referral, escalation, repeat tests.
Contact attempts	Phone, SMS, email, letter, emergency contact, dates/times.
Patient discussion	What was explained, questions, patient response.
Open disclosure	Acknowledgement, apology/expression of regret, factual explanation, patient questions.
Follow-up	Named responsible clinician, timeframe, appointment.
Reporting	Incident register, SEA/RCA, MDO advice if relevant.
Quality improvement	System changes, staff education, audit plan.

Use a dated addendum if further clarification is required. Do not alter old notes.

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Step 4 — Internal Reporting

General practice should record incidents and near misses in an incident register.

Field	Example
Date identified	20/05/2026
Incident type	Abnormal result not actioned
Severity	Near miss / minor harm / moderate harm / severe harm
Immediate action	Patient contacted, urgent review arranged
Open disclosure	Patient informed, apology given, plan explained
Contributing factors	Result filed without clear action; no escalation process
Responsible person	Treating GP / practice manager
Corrective action	Recall protocol updated
Review date	One-month audit

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Step 5 — Significant Event Analysis

A Significant Event Analysis is useful because many GP adverse events are system-related rather than purely individual failures.

Question	Purpose
What happened?	Establish facts and timeline.
Why did it happen?	Identify contributing factors.
What was the impact?	Patient harm, staff impact, system impact.
What went well?	Identify protective factors.
What could have gone better?	Identify gaps.
What will we change?	Corrective actions.
How will we know it worked?	Audit, monitoring, feedback.
How will we communicate outcomes?	Inform patient/family and staff of review findings and changes where appropriate.

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Root Cause Analysis Checklist

Use this instead of asking “Who is to blame?”

Domain	Questions
Patient	Complex case? Language barrier? Missed appointment? Incorrect contact details?
Task	Was the task clear? Was it urgent? Was there a protocol?
Clinician	Fatigue? Knowledge gap? Cognitive bias? Workload?
Team	Was handover clear? Were roles defined?
Environment	Interruptions? Running late? Staffing shortage?
Technology	Software issue? Wrong file? Failed reminder?
Organisation	Policy absent? Poor induction? No audit?
External	Hospital delay? Referral rejected? Pathology communication issue?
Communication after event	Was open disclosure timely, factual, empathetic and documented?

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Preventing Recurrence: System Changes

Recall and Results System

Risk	Prevention Strategy
Abnormal result missed	All incoming results must be reviewed and actioned by a GP.
Result filed without action	Mandatory “result actioned” field before filing.
No tracking of urgent results	Urgent result register or dashboard.
Patient not contacted	Documented contact attempts with escalation pathway.
Test ordered but not completed	Reminder system for non-attendance.
Referral lost	Track urgent referrals until appointment confirmed.
GP away	Buddy system for inbox/result coverage.

Practical Escalation Policy for Abnormal Results

Step	Action
1	Phone patient for clinically significant abnormal result.
2	If no answer, leave safe generic message if appropriate.
3	Send SMS requesting urgent contact or appointment, avoiding sensitive detail unless consented.
4	Repeat phone contact.
5	Send letter.
6	Send registered letter for significant unresolved abnormal result.
7	Use emergency contact if serious clinical risk and appropriate.
8	Consider welfare check / ambulance / ED escalation if immediate risk.
9	Document all attempts.
10	Keep result open until resolved.

Clear Responsibility

A useful practice rule:

The requesting doctor remains responsible for ensuring clinically significant results are reviewed, actioned and followed up, unless responsibility is clearly transferred and documented.

Role	Responsibility
Requesting GP	Review, interpret and action results.
Covering GP	Manage results when requesting GP absent.
Admin	Contact patient according to protocol.
Nurse	Assist with triage, patient education, repeat tests.
Practice manager	Maintain recall system, audits, incident register.

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Medication Safety Strategies

Strategy	Examples
Medication reconciliation	After hospital discharge, specialist letters, RACF reviews.
High-risk drug register	Warfarin/DOACs, insulin, methotrexate, lithium, opioids.
Renal dosing checks	eGFR before NSAIDs, DOACs, metformin, antibiotics.
Allergy verification	Check before prescribing antibiotics, NSAIDs, opioids, contrast.
Monitoring reminders	UEC, LFT, FBC, TFT, INR, lithium levels as appropriate.
Limit unsafe repeats	Review indication, duration and monitoring before ongoing scripts.
Pharmacist collaboration	HMR, RMMR, medication review.

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Reducing Diagnostic Error

Strategy	Examples
Consider “worst first”	Rule out ACS, sepsis, ectopic pregnancy, SAH, meningitis before benign diagnosis.
Use red-flag checklists	Chest pain, headache, abdominal pain, back pain, paediatrics.
Safety-net clearly	What to watch for, when to return, when to call ambulance.
Arrange planned review	Especially where diagnosis uncertain.
Revisit diagnosis	“What else could this be?”
Use decision support	Therapeutic Guidelines, HealthPathways, RACGP resources.
Seek second opinion	Supervisor, peer GP, specialist phone advice, ED discussion.

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Communication Safety

Situation	Safer Approach
Complex instructions	Written plan + teach-back.
Urgent referral	Phone call + written referral + tracking.
Abnormal result	Direct contact; do not rely on routine SMS alone.
Handover	Use structured handover: situation, background, assessment, recommendation.
RACF escalation	Clear parameters: symptoms, vitals, when to call GP/ambulance.
Language barrier	Use professional interpreter, not family for critical decisions.
After adverse event	Open disclosure, factual explanation, apology, follow-up and documented system review.

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Medical Defence / Medico-Legal Points

For significant harm, delayed diagnosis, death, medication harm, confidentiality breach, complaint risk or regulatory risk:

Action	Reason
Contact MDO early	Advice on disclosure, documentation and complaint response.
Do not alter old notes	Use dated addendum only.
Preserve records	Notes, results, referrals, messages, call logs.
Avoid blame/speculation	Stick to known facts.
Do not admit liability	Apologise or express regret, but avoid legal conclusions.
Continue care if appropriate	Do not abandon the patient.
Support staff	Clinicians may experience guilt, distress and loss of confidence after adverse events.

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GP Adverse Event Note Template (example)

Event

Patient experienced an adverse event involving:

• Delay in communication of abnormal result
• Medication prescribing error
• Missed recall
• Delayed referral
• Incorrect vaccination/storage issue
• Documentation or handover failure

Example:

Delay in communication of abnormal pathology/imaging result requiring clinical follow-up.

Immediate Clinical Assessment

Patient contacted/reviewed on:
Current symptoms/clinical status:
Immediate risk assessed: low / moderate / high
Urgent care required: yes / no

Actions taken:

• Clinical review arranged.
• Repeat test/investigation requested.
• Medication changed/ceased if relevant.
• Referral arranged.
• ED transfer arranged if clinically indicated.
• Safety-netting provided.
• Follow-up appointment booked.

Open Disclosure

• Adverse event acknowledged with patient/family.
• Apology or expression of regret provided.
• Known facts explained clearly.
• Speculation and blame avoided.
• Patient given opportunity to ask questions and describe concerns.
• Follow-up plan agreed.
• Patient advised that the event will be reviewed.
• Patient advised that relevant findings and system changes will be communicated where appropriate.

example……..

I explained that there had been a delay/error in [brief factual description]. I apologised for the distress and potential harm caused. I explained the known facts, advised that the matter would be reviewed, and discussed the immediate clinical plan. The patient was given the opportunity to ask questions and express concerns. Follow-up arrangements were agreed.

Contributing Factors

Patient Factors

• Outdated or incorrect contact details.
• Non-response to calls/messages.
• Difficulty understanding recall instructions.
• Complex psychosocial circumstances.

Practitioner Factors

• Delayed review of result.
• Unclear follow-up plan.
• Cognitive overload/fatigue.
• Competing clinical priorities.

System Factors

• Inadequate recall/reminder system.
• Unclear delegation between clinician and admin staff.
• No escalation pathway for abnormal results.
• IT limitations.
• Lack of audit process.
• Inadequate documentation/handover.

Environmental Factors

• High workload.
• Staffing shortages.
• Communication gaps.
• Interruptions or workflow pressure.

Swiss Cheese Model Interpretation

This adverse event likely resulted from multiple aligned failures rather than one isolated mistake.

Possible layers:

• Abnormal result generated.
• Result not reviewed promptly.
• Recall not actioned or escalated.
• Patient not contacted successfully.
• No audit detected the unresolved result.

This reflects both:

• Active errors — actions or omissions at the point of care.
• Latent system failures — weaknesses in processes, IT systems, escalation pathways, staffing or governance.

Management Plan

Patient Care

• Assess current clinical risk.
• Arrange appropriate investigations/treatment.
• Escalate to ED/specialist care if clinically indicated.
• Provide clear safety-net advice.
• Arrange follow-up appointment.
• Document all communication.

Communication

• Provide open disclosure.
• Offer written summary if appropriate.
• Provide contact person for further questions.
• Offer opportunity to speak with another clinician.
• Update patient/family after review where appropriate.

Practice/System Improvement

• Incident report completed.
• Recall and results-management process reviewed.
• Responsibility for abnormal result follow-up clarified.
• Escalation pathway for urgent/abnormal results implemented.
• Patient contact details checked at each visit.
• Audit of outstanding recalls/results arranged.
• Staff education/debrief completed.
• Effectiveness of changes reviewed.