Table 2.
The triggers we identified in our study are presented with PPV with 95% CI for identifying harm
| Item | PPV (CI)% |
|---|---|
| General care | |
| PG1 Early warning score | |
| PG2 Tissue damage or pressure ulcer | |
| PG3 Readmission within 30 days | 24/175=14 (9 to 20) |
| PG4 Unplanned admission | |
| PG5 Abnormal cranial imaging | |
| PG6 Respiratory or cardiac arrest/crash calls | 0/1=0 (0 to 95) |
| PG7 Diagnostic imaging for embolus/thrombus +/− confirmation | 1/2=50 (3 to 97) |
| PG8 Complication of procedure or treatment | 17/23=74 (51 to 89) |
| PG9 Transfer to higher level of care | 3/22=14 (4 to 36) |
| PG10 Hypoxia O2 saturation <85% | 0/25=0 (0 to 17) |
| PG11 Cancelled elective procedure/delayed discharge | 1/1=100 (5 to 100) |
| Surgical care | |
| PS1 Return to theatre | 1/1=100 (5 to 100) |
| PS2 Change in planned procedure | |
| PS3 Surgical site infection or hospital acquired urinary tract infection | 6/6=100 (52 to 100) |
| PS4 Removal/injury/repair of organ | |
| Intensive care | |
| IP1 Readmission to intensive care or high-dependency care | |
| Medication | |
| PM1 Vitamin K (except for routine dose in neonates) | |
| PM2 Naloxone | |
| PM3 Flumazenil (romazicon) | |
| PM4 Glucagon or glucose ≥10% | |
| PM5 Chlorphenamine or antihistamine | 0/1=0 (0 to 95) |
| PM6 Antiemetics | |
| PM7 IV Bolus ≥10 mL/kg colloid or crystalloid given | 3/19=16 (4 to 40) |
| PM8 Abrupt medication stop | |
| Lab test | |
| PL15 Thrombocytopenia (platelets <100) | 0/7=0 (0 to 44) |
| PL1 High INR >5 or a PTT >100 | |
| PL2 Transfusion | 2/8=25 (4 to 64) |
| PL3 Abrupt drop in Hb or Hct (>25%) | 2/8=25 (4 to 64) |
| Biochemistry | |
| PL4 Rising urea or creatinine (>2× baseline) | 0/1=0 (0 to 95) |
| PL5/PL6 Electrolyte abnormalities (Na+ <130 or >150, K+ <3.0 or >6.0) | 0/12=0 (0 to 30) |
| PL7 Hypoglycaemia (<3 mmol/L) | 3/8=38 (10 to 74) |
| PL8 Hyperglycaemia (>12 mmol/L) | 0/1=0 (0 to 95) |
| PL9 Drug level out of range | |
| Microbiology | |
| PL10 MRSA bacteraemia | |
| PL11 Clostridium difficile | |
| PL12 VRE | |
| PL13 Nosocomial pneumonia | 2/2=100 (20 to 100) |
| PL14 Positive blood culture | 1/1=100 (5 to 100) |
| Other | |
| PO1 Other event | |
The numerator represents number of harm events and the denominator how many times each individual trigger was found in all patient contacts (n=761).
Hb, haemoglobin; HCT, haematocrit; INR, international normalised ratio; MRSA, methicillin-resistant Staphylococcus aureus; PPV, positive predictive value; VRE, vanc resistant enterococcus.