Step 4

Rate Severity

AE 99
Description: NO AE
Definition: A case where a Trigger was selected (e.g., cardiac arrest during transport), but no AE identified after full review.
Example(s): Cardiac arrest during transport, but all documentation supports the crews committed no error and followed protocol(s) as prescribed. Trigger selected due to administration of a medication (e.g., naloxone). However, the use of naloxone was indicated for patient overdose of opiate and is not related to delivery of care (e.g., the crewmembers did not overdose the patient). The time to transport the patient was delayed for necessary care, diagnostic procedures, or interventions outside control of medical crew (e.g. the patient was in the CT scanner at the referring facility or the patient requires a balloon pump, which will require longer time at bedside during the transition of care). Missing, incomplete, or unclear documentation.

2 Categories of AE Severity
Category 1
Description: AE present – Potential for Harm (AE 1)
Definition: An action that may lead to injury or harm but there is NO evidence that an injury or harm occurred.
Example(s): A medication error in which one type of medication (e.g., ketamine) was administered to an intubated patient for sedation in place of more appropriate medication or medication listed as the standard of care (off-line protocols e.g., Versed). A 22kg pediatric burn patient received 0.2mg/kg of morphine (4.4mg total) for pain rather than 0.1mg/kg (2.2mg total). The pediatric patient may exhibit no adverse reactions (i.e. hypotension and reduced respirations). Administration of 500cc of saline when 300cc bolus was ordered by medical oversight. Patient received 4mg of Midazolam when the oversight physician ordered 2mg. Failure to administer ASA for a patient with chest pain for suspected cardiac etiology. Failure to check vital signs before and after medication administration (i.e., Nitroglycerin). Not adequately protecting patient’s airway. For example, no airway adjunct utilized for an unconscious patient with normal vital signs and no evidence of desaturation. Stretcher dropped or tipped, but no evidence the patient or crew member(s) were injured. Failure to immobilize a fracture in a trauma patient. Failure to control hemorrhage in a hemodynamically stable patient. Administration of Nitroglycerin to patient with documented use of phosphodiesterase inhibitors (e.g., Viagra). No evidence of hypotension is found. Immediately recognized and quickly corrected missed intubation with no evidence of patient deterioration.

Category 2
Description: AE present – Harm Identified (AE 2)
Definition: An action or omission that led to injury or harm regardless of severity.
Example(s): Delay in recognition of missed intubation with evidence of patient deterioration; or failure to control airway within a reasonable amount of time or number of attempts with evidence of patient deterioration. A seizure patient administered 4mg Midazolam when medical oversight gave orders for 2mg. The patient lost spontaneous respirations. Crewmembers responded by use of BVM ventilations and intubation. Crew member intends to administer amiodarone for treatment of wide complex tachycardia at rate of 160. Crew member administers 10 mg Diltiazem and patient suffers a v-fib arrest. Stretcher drop with injury to patient. Failure to administer eclamptic patient Magnesium Sulfate and then seizes for a period of time. Patient with a GCS ≤8 and evidence of respiratory compromise (i.e., SPO2 <90) but no airway intervention by crewmembers. Crewmembers fail to activate specialty team where indicated (i.e. trauma team, cath lab, stroke alert). Failure to decompress a tension-pneumothorax Failure to adequately sedate a patient that was intubated as evidenced by follow-up from receiving facility that documented patient recall of events. Administration of Nitroglycerin to patient with documented use of phosphodiesterase inhibitors (e.g., Viagra). Hypotension results. A patient suffering from anaphylatic reaction is administered 0.3mg of Epinephrine 1:1000 Intravenous (IV) instead of Intramuscular (IM) and develop acute chest pain and change on EKG monitor. Use of unsynchronized cardioversion in a patient with unstable Atrial Fibrillation (Afib) that results in Ventricular Fibrillation (Vfib) or asystole.