Table 2.
Event Type | Reported | Subgroup | N (total n=79) |
---|---|---|---|
Care Module (n=25) | C1 | Transfusion or use of blood products | 8 |
C2 | Code/arrest/rapid response team | 2 | |
C4 | Positive Blood Culture | 1 | |
C7 | Patient fall | 2 | |
C9 | Readmission Within 30 Days | 1 | |
C11 | Healthcare-associated infection | 4 | |
C14 | Any procedure complication | 4 | |
C15 | Other | 3 | |
Medication Module (n=52) | M4 | Glucose less than 50 mg/dl | 1 |
M5 | Rising BUN or serum creatinine | 1 | |
M6 | Vitamin K administration | 1 | |
M7 | Benadryl (Diphenhydramine) use | 2 | |
M10 | Anti-emetic use | 5 | |
*zofran, ativan, compazine, zyprexia, reglan, vanco, omnipaque, gadovist | |||
M11 | Over-sedation/hypotension | 6 | |
M12 | Abrupt Medication Stop | 16 | |
*morphine, oxycodone, pepcid, amlodipine, lisinopril, lovenox, ASA, metoprolol, atenolol, oxycontin, dilaudid, haldol, dexamethasone, cefepime | |||
M13 | Other | 20 | |
*neupogen, allupurinol, oxycodin, dexamethasone, amodipine, hydralazine | |||
Intensive Care Module (n=2) | I1 | Pneumonia onset | 1 |
I3 | In-Unit Procedure | 1 | |
Harm Code | Definition | N (total n=79) | |
A | Circumstances or events that have the capacity to cause error | 1 | |
B | An error that did not reach the patient | 0 | |
C | An error that reached the patient but did not cause harm | 5 | |
D | An error that reached the patient and required monitoring or intervention to confirm that it resulted in no harm to the patient | 32 | |
E | Temporary harm to the patient and required intervention | 35 | |
F | Temporary harm to the patient and required initial or prolonged hospitalization | 5 | |
G | Permanent patient harm | 0 | |
H | Intervention required to sustain life | 0 | |
I | Patient death | 1 | |
Preventability | N (total n=79) | ||
Definitely Preventable | 9 | ||
Probably Preventable | 12 | ||
Probably Not Preventable | 40 | ||
Definitely Not Preventable | 18 |
medications taken directly from EHR description of Global Trigger Tool AE analysis during chart review