Table 2. Examples of patient safety events.

Category	Example
Data exchange failure	Nurse unable to dispense a medication routed to medication dispensing machine due to discrepancy between stock listed in EHR and in medication dispensing machine database
Primary product failure	Pharmacy medication preparation report generation takes an excessive amount of time
Usability/use error (not otherwise specified)	Chemotherapy orders do not prompt for second signature because system requires user to change context for prompt to appear
Difficulty/error entering data	Provider selected default dose when ordering medication, and the dose was too high
Difficulty navigating EHR workflow	Orders were not “released” by provider within the EHR
Difficulty interpreting displayed information	Staff member did not scroll down completely to see medication administration schedule, and medication dose was missed
Faulty process design choices	Scheduled inpatient medications are not dispensed from pharmacy while patient is in operating room, leading to missed dose
Setup incorrect	Dose rounding parameters for neonates are imprecise (e.g., rounding to nearest 0.1 mL instead of 0.01 mL)

Abbreviation: EHR, electronic health record.