Case studies

Treatment Injury case studies

These case studies are produced by ACC’s Treatment Injury Centre, to provide health professionals with:

  • an overview of the factors leading to treatment injury
  • expert commentary on how similar injuries might be avoided in the future.

The case studies are not intended as a guide to treatment injury cover.

Please send your feedback to:

ACC is working with the Health Quality and Safety Commission (HQSC) and the Health and Disability Commissioner (HDC) to publish lessons learnt from adverse event reviews and complaint investigations.

Treatment event

Treatment injury


Intravenous cannulation (PDF 579K)


September 2015

Medication administration (PDF 103K)

Aspiration pneumonia

July 2015

Anaesthetic medication administration (PDF 489K)

No injury

June 2015

Wrong treatment (PDF 491K)

Wrong-site surgery

March 2015

Medication adverse event (PDF 106K)

Blindness/Visual disturbance

February 2015

Drug-induced liver injury (DILI) (PDF 110K)

Drug-induced hepatitis

January 2015

Delay in diagnosis of subarachnoid haemorrhage (PDF 112K)

Brain injury

December 2014

Immobility following a fracture (PDF 105K)

Pressure injuries

November 2014

Equipment retained (PDF 490K)

Wound infection

October 2014

Wrong site surgery (PDF 506K)

Unnecessary incisions

September 2014

Medication dispensing error (PDF 111K)

Drug-induced hepatitis

August 2014

Medication administration (PDF 106K)

Cardiac arrest and resultant death

July 2014

Adverse drug reaction (PDF 114K)

Foetal valproate syndrome

June 2014 (2)

Adverse drug reaction (PDF 111K)

Interstitial pneumonitis

June 2014 (1)

ACC treatment injury data patterns and learning (PDF 118K)

May 2014

Endometrial thermal ablation (PDF 109K)

Intra-abdominal burns

April 2014

Medication adverse drug reaction (PDF 109K)

Osteonecrosis of jaw

January 2014

Delay/failure in diagnosing meningitis (PDF 143K)


November 2013

Medication administration (anaesthesia) (PDF 107K)

No treatment injury

October 2013

Bridging anticoagulation (PDF 111K)

Ischaemic stroke

September 2013

Adverse drug reaction (PDF 603K)

Vestibular damage & bobbing oscillopsia

August 2013

Delay in diagnosis of acute appendicitis in pregnancy (PDF 115K)

Ruptured appendix

July 2013

Adverse drug reaction (PDF 146K)

Pulmonary fibrosis

June 2013

Use of anti-embolic stockings (PDF 114K)

Gangrene, nerve injury and skin tear

May 2013

Insulin overdose (PDF 117K)

No treatment injury

April 2013

Delay in diagnosis (PDF 118K)

Loss of vision

March 2013

Theatre positioning (PDF 112K)

Radical nerve compression

February 2013

Reporting belief of risk of harm to the public (PDF 116K)

Medication events

January 2013

Plaster cast (PDF 109K)

Pressure injury

November 2012

Dabigatran usage (PDF 111K)

Ischaemic stroke

October 2012

Prolonged Nitrofurantoin usage (PDF 141K)

Pulmonary toxicity

September 2012

Wrong site of ventrogluteal injection (PDF 110K)


August 2012

Surgery to prevent risk of ovarian cancer (PDF 245K)

Unnecessary surgery

July 2012

Failure of hip replacement (PDF 270K)

Metallosis reaction

June 2012

Paracetamol poisoning (PDF 403K)

No treatment injury

May 2012

Alleged delay in diagnosis of metastatic melanoma (PDF 263K)

No treatment injury

April 2012

Delay in diagnosis of appendicitis (PDF 262K)

Perforated appendix and peritonitis

March 2012

Delay in diagnosis of cauda equina syndrome (PDF 267K)

Spinal cord damage

February 2012

Delay in diagnosis (PDF 344K)

Progression of slipped capital femoral epiphysis (SCFE)

December 2011

Delay in diagnosis (PDF 370K)

Progression of cervical cancer

November 2011

Failure to prescribe anticoagulation (PDF 377K)

Embolic stroke

October 2011

Failure to treat neonatal hypoglycaemia (PDF 344K)

Brain damage

September 2011

Urinary catheterisation (PDF 221K)

Urethral damage

August 2011

Patient transfer (PDF 263K)

Hip fracture

July 2011

Delay in diagnosing subarachnoid haemorrhage (PDF 362K)

Brain damage

June 2011

Delay in treatment of neonatal jaundice (PDF 359K)


May 2011

Nursing care (PDF 411K)

Pressure ulcer

April 2011

Delay in diagnosis (PDF 224K)

Progression of breast cancer

March 2011

Hysterectomy (PDF 220K)

Ureteric injury

February 2011

Total knee joint replacement (PDF 252K)

Surgical site infection

December 2010

Central venous cannulation (PDF 251K)

Catheter-related bloodstream infection

November 2010

Heat treatment (PDF 228K)


October 2010

Unsterile equipment and wrong patient (PDF 194K)

No treatment injury

September 2010

Delay in delivery (PDF 192K)

Neonatal encephalopathy

August 2010

Delay in treatment (PDF 219K)

Brain damage/injury

July 2010

Delay in diagnosis (PDF 210K)

Progression of lung cancer

June 2010

Warfarin and aspirin (PDF 243K)

Cerebral haemorrhage

May 2010

Long-term lithium treatment (PDF 124K)

Chronic renal failure

April 2010

Phosphate-containing bowel preparation (PDF 122K)

Renal failure

March 2010

IV cannulation (PDF 124K)

Cellulitis and nerve damage

February 2010

Medication administration error (PDF 122K)

No treatment injury

December 2009

Failure to diagnose epidural abscess (PDF 142K)


November 2009

Laparoscopic cholecystectomy (PDF 140K)

Bile duct injury

October 2009

Alleged delay in diagnosis of spinal TB (PDF 140K)

No treatment injury

September 2009

Feedback from health professionals on how previous treatment injury case studies are being used

August 2009

Failure to follow up report results (PDF 126K)

Recurrent appendicitis

July 2009

Nursing care (PDF 138K)

Pressure ulcers

June 2009

Failure to diagnose temporal arteritis (PDF 139K)


May 2009

Steroid therapy (PDF 126K)


April 2009

Failure to diagnose varicella pneumonia (PDF 131K)


March 2009

Dispensing error (PDF 130K)

Symptoms of possible prednisone overdose (no injury)

February 2009

Gynaecological mesh placement (PDF 133K)


November 2008

Erythromycin and simvastatin interaction (PDF 153K)


October 2008

Intravenous infusion (PDF 131K)

Osmotic myelinolysis or extra pontine myelinolysis

September 2008

Medication (PDF 132K)

Hyponatraemia resulting in extra pontine myelinolysis

August 2008

Splitting of plaster cast (PDF 131K)

Volkmann’s contracture

July 2008

Gastroscopy and colonoscopy (PDF 151K)

Perforated bowel

June 2008

Testicular torsion (PDF 151K)


May 2008

Ear syringing (PDF 570K)

Perforated eardrum

April 2008

Reviewed: 16 May 2016