Table 5.

Examples of Observed Errors

Observed Error Synopsis
• An intern discusses a case with the attending physician, but fails to mention that the patient has a blood pressure of 149/106. None of the nurses or technicians in attendance mentions this to the attending, nor do they recheck the blood pressure.
• The patient had been exposed to a toxic agent. The nurse with the patient did not inform the physician that the patient was designated a “contact precaution.” The physician did not check the chart, and examined the patient without gloves.
• Nurse did not include ipratropium in a nebulizer treatment as ordered.
• A trauma patient, brought in by ambulance, was receiving oxygen by mask. The mask was left in place but not hooked up to the oxygen flow meter in the room.
• A patient with chest pain was placed in a bed by a technician who did an EKG and placed the strip in the patient's chart. The patient was then unobserved for 25 minutes. The nurse and physician were unaware the patient was present in the bed.