Table 4.

Example Vignettes

Category	Subcategory	Modifiers	MERP	Site*	Event Narrative
Ancillary Services	Wrong Exam/Patient/Result/Test	Lab Services	B	ED	Point of care INR test result was high, prompting ordering of reversal agents. These were then cancelled when whole blood INR resulted withing normal range.
	Wrong Exam/Patient/Result/Test	Radiology	D	ED	Initial ED CT scan interpretation of a peri-colonic abscess prompted admission for operative management. The following day, re-review of the CT determined there was no fluid collection or abscess and the patient was discharged.
	Specimen Related Issue	Blood Bank	B	ED	Type & screen sample for ED patient waiting to go to the OR was lost. New sample had to be sent and procedure was delayed.
Care Coord.	Inter-/Intra-departmental Communication Issue	(None)	C	ED	Patient taken urgently to OR from the ED without chart, allergy band, or name band.
	Documentation Issue	Wrong Patient/ Site/ Procedure	A	ED	MD note documented 2 EKG interpretations; one was for a different patient.
	Discharge Instructions Issue		A	ED	Patient sent home with wrong discharge instructions.
Device	Malfunction/ Migration/ Occlusion	Pulmonary; Procedural	D	ED	During procedural sedation team observed “loss of capnography likely due to equipment malfunction.” Patient had BVM ventilatory assistance; no decrease in oxygen saturation.
	Infiltration/Extravasation	Vascular	D	ED	Patient’s iv access infiltrated and was removed. No further intervention.
Medication	Over-anticoagulation		D	POA	Patient on coumadin with INR 6.5 in the ED (and no bleeding). IV vitamin K ordered, administered, and patient was monitored.
	Wrong Dose/ Medication/ Route/ Order/ Patient	(None)	A	ED	Insulin ordered on wrong patient, but not administered.
	Other	Electrolyte abnormality	D	POA	Incidental finding of hypokalemia thought due to patient’s home diuretic medications. Asymptomatic (so no AE) and treated with po replacement.
	Allergic Reaction	Opioids	D	ED	4mg morphine ordered, stopped at 2mg infused due to itching and redness at iv site. No intervention required.
Patient Care	Failure to Monitor	Fall/Fall Risk	C	ED	Patient with altered mental status and designated as a fall risk found ambulating throughout the ED.
	Delayed Treatment	ED Boarding/Crowding	A	ED	Delay in initial and scheduled antibiotic administration in patient with prolonged ED waiting room and boarding times.
	Delayed Treatment	ED Boarding/Crowding	A	ED	Patient with chief complaint of abdominal pain (ESI 3) had a 6hr waiting room LOS before placement in ED treatment room.
	Transfusion Reaction	(None)	D	ED	Intubated patient developed hives after being given multiple units of blood products. Monitored without other intervention or changes in care.
	Other	Language Barrier/ Interpreter Services	A	ED	Translator phone service broken. Patient’s husband had to call their son to translate.
Surgery/ Procedural	Malposition	GI	D	ED	Nasogastric tube placed for medication administration was curled in esophagus on xray requiring advancement and repositioning
	Bleeding	GU	D	ED	Blood noted after urinary catheter placement. Monitored, without further interventions required.