Table 2.

Infrequent but Important Patient Safety Incidents Associated with Significant Harm

(1) Burns and fires caused by smoking/sparks/flame near a patient using oxygen at home

• Harms ranged from small facial burns to significant structural fires causing death

(2) Patient suicide by violent means while enrolled in hospice care

• Harm to the patient is obvious, but emotional harm to family, caregivers, and hospice team members described as severe and long lasting

(3) Multiple shocks from an internal defibrillator during a patient's final dying process

• Harms include significant discomfort at the moment of death for the patient, and emotional harm to those who witness the patient's death

(4) Unintended overdose of an opioid administered by a family caregiver

• Harms ranged from temporary oversedation to possible hastening of death in an actively dying patient, and significant emotional distress for caregivers