Table 1.

Patient safety incident types identified by the peer review committee

PSI type	Definition	Example
Systems failures
Triage	A failure in assessment of potential disease severity during triage	Abnormal vital signs not recognized as a potential sign of shock
ED teamwork	A failure due to an issue with ED staff communication or a shared responsibility across multiple ED staff	Change in vital signs not communicated to the attending physician
Hospital Teamwork	A failure due to an issue with communication between ED and hospital staff or a shared responsibility between the ED and hospital staff	Pertinent information not communicated to the admitting team
ED work environment	A failure resulting from the lack, malfunction, or mal-design of resources, equipment or physical space within the ED or a failure resulting from following an established ED policy or clinical practice guideline	Missing equipment needed for care of a patient
Hospital work environment	A failure resulting from the lack, malfunction, or mal-design of resources equipment or physical plant outside the ED but still within the hospital or a failure resulting from following an established hospital policy or guideline	Specialty testing areas remotely located from the ED causing prolonged transport time
Boarded patient	A failure occurred after the patient was admitted to an in-patient service but was still physically in the ED	N/A
Practitioner-based errors
Major cognitive error	An error in cognition which represents serious mismanagement in a knowledge area basic to emergency	Failure to diagnose and treat ST-elevation myocardial infarction
Cognitive error	An error in cognition which represents mismanagement which is either less serious than a major cognitive error or in an area less basic to emergency medicine	Failure to consider the institutional antibiogram during antibiotic selection for treatment
Missed radiographic finding	An error in interpretation of a radiographic study that did not reach the level of a cognitive or major cognitive error	Missed fracture on radiographic interpretation that was still splinted based on clinical suspicion
Policy deviation	An error in following a clinical or administrative policy, guideline or standard practice that does not reach the level of cognitive or major cognitive error	Failure to alert the transplant service when a transplant patient is in the ED
Procedural error	A technical error during performance of a procedure that does not reach the level of a cognitive or major cognitive error	Insufficient sterile technique