Table 3.
N | As % of category | As % of all near misses | |
---|---|---|---|
Patient Care | |||
Delayed Treatment | 1,002 | 89.1% | 68.7% |
Delayed Diagnosis | 11 | 1.0% | 0.8% |
Other | 90 | 8.0% | 6.2% |
Failure To Monitor | 15 | 1.3% | 1.0% |
Hypotension | 3 | 0.3% | 0.2% |
Transfusion Reaction | 3 | 0.3% | 0.2% |
Fall | 1 | 0.1% | 0.1% |
Medication | |||
Other | 150 | 60.5% | 10.3% |
Wrong Dose/ Medication/ Route/ Order/ Patient | 80 | 32.3% | 5.5% |
Allergic Reaction | 7 | 2.8% | 0.5% |
Hypoxia | 4 | 1.6% | 0.3% |
Delirium, Confusion | 2 | 0.8% | 0.1% |
Hypotension | 2 | 0.8% | 0.1% |
Bleeding | 1 | 0.4% | 0.1% |
Nausea And Vomiting | 1 | 0.4% | 0.1% |
Over-anticoagulation | 1 | 0.4% | 0.1% |
Ancillary Services | |||
Delay | 22 | 50.0% | 1.5% |
Wrong Exam/ Patient/ Result/ Test | 12 | 27.3% | 0.8% |
Specimen-related issue | 8 | 18.2% | 0.5% |
Other | 2 | 4.5% | 0.1% |
Care Coordination | |||
Inter-/ Intra-dept Communication Issue | 11 | 61.1% | 0.8% |
Documentation Issue | 3 | 16.7% | 0.2% |
Sending Institution Communication Failure | 2 | 11.1% | 0.1% |
Other | 1 | 5.6% | 0.1% |
Outpatient Coordination / Communication Issue | 1 | 5.6% | 0.1% |
Surgery/ Procedural | |||
Malposition | 10 | 66.7% | 0.7% |
Bleeding | 3 | 20.0% | 0.2% |
Other | 2 | 13.3% | 0.1% |
Device | 0.0% | ||
Malfunction/ Migration/ Occlusion | 4 | 50.0% | 0.3% |
Infiltration/Extravasation | 2 | 25.0% | 0.1% |
Other | 2 | 25.0% | 0.1% |