Table 5. – Cross cutting themes.
Frequency = Number of near misses with term / total number of near misses (=1,458)
| item | N | Frequency |
|---|---|---|
| Delayed treatment | 1,012 | 69% |
| ED boarding/crowding | 997 | 68% |
| Other | 247 | 17% |
| Documentation issue | 238 | 16% |
| Medication Administration Error (wrong dose/ medication/ route/ order/ patient) | 80 | 5% |
| Psychiatric | 32 | 2% |
| Delay | 22 | 2% |
| Failure to monitor | 21 | 1% |
| Delayed diagnosis | 20 | 1% |
| Radiology | 19 | 1% |
| Opioids | 18 | 1% |
| Lab services | 13 | 1% |
| Wrong exam/ patient/ result/ test | 12 | 1% |
| Fall/ fall risk | 11 | 1% |
| Inter-/ intra-departmental communication issue | 11 | 1% |
| Malposition | 10 | 1% |
| Blood bank | 9 | 1% |
| Gastrointestinal | 9 | 1% |
| Specimen-related issue | 8 | 1% |
| Allergic reaction | 7 | 0% |
| Cardiac | 7 | 0% |
| Pharmacy | 6 | 0% |
| Benzodiazepines | 5 | 0% |
| Hypotension | 5 | 0% |
| Intubation/ airway | 5 | 0% |
| Language barrier/interpreter services | 5 | 0% |
| Neurological | 5 | 0% |
| Procedural | 5 | 0% |
| Test/lab result | 5 | 0% |
| Vascular | 5 | 0% |
| Bleeding | 4 | 0% |
| Genitourinary | 4 | 0% |
| Hypoxia | 4 | 0% |
| Malfunction/ migration/ occlusion | 4 | 0% |
| Orthopedic | 4 | 0% |
| Propofol | 4 | 0% |
| Wrong patient/site/procedure | 4 | 0% |
| Self injury | 3 | 0% |
| Transfusion reaction | 3 | 0% |
| Cascading event | 2 | 0% |
| Delirium, confusion, oversedation, mental status | 2 | 0% |
| Electrolyte abnormality | 2 | 0% |
| Glycemic event | 2 | 0% |
| Infiltration/extravasation | 2 | 0% |
| Iv contrast | 2 | 0% |
| Pulmonary | 2 | 0% |
| Sending institution failure to communicate | 2 | 0% |
| Angioedema | 1 | 0% |
| Confusion | 1 | 0% |
| Delay in ordering (consultation, lab, imaging) | 1 | 0% |
| Dysrhythmia | 1 | 0% |
| Otolaryngology | 1 | 0% |
| Nausea and vomiting | 1 | 0% |
| Outpatient coordination or communication issue | 1 | 0% |
| Over-anticoagulation | 1 | 0% |
| Sepsis | 1 | 0% |
| Skilled Nursing Facility/ Home Health / Nursing Home | 1 | 0% |