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. Author manuscript; available in PMC: 2024 Mar 1.
Published in final edited form as: J Patient Saf. 2023 Jan 7;19(2):59–66. doi: 10.1097/PTS.0000000000001092

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%