Table 1.

Number of Process of Care Problems

	Events
	n	%
Diagnosis
Inadequate evaluation	18	16.4
Diagnostic error	7	6.4
Delayed consultation	4	3.6
Therapy
Medication-related
Drug reaction	5	4.5
Delay in providing medication	5	4.5
Failure to order medication	1	0.9
Inappropriate medication	1	0.9
Operative or procedure-related
Delayed procedure or operation	2	1.8
Postprocedure complication	6	5.5
Other treatment-related problem
Inappropriate treatment	2	1.8
Prevention
Failure to monitor or follow-up	14	12.7
Inadequate supervision	3	2.7
Clinical services
Failure of laboratory or radiologyto perform a test	14	12.7
Failure of laboratory or radiologyto report abnormal results	2	1.8
Laboratory error	2	1.8
Support services
Failure to transport a patient	4	3.6
Failure to draw blood	3	2.7
Inadequate supplies	2	1.8
Failure to provide for patient comfort	2	1.8
Discharge planning and code status
Difficult or unsafe discharge	6	5.5
Problem with code status	4	3.6
Other events
Unavailable intensive care unit bed	2	1.8
Inadequate staffing	1	0.9
Total	110	100.0