Treatment – No Order For Treatment – Wrong Patient Unexpected Cardiac and/or Respiratory Arrest Requiring ACLS Intervention Diagnostic Imaging Contrast – Allergic Reaction Contrast – Event Contrast – Extravasation Equipment – Failure/Malfunction Equipment – Maintenance Issue Exposure – Overexposure Exposure – Unanticipated Radiation Exposure Film Unavailable or Inadequate Image – Incorrect Infiltration Event MRI Safety Issue Other Patient Incorrect Process – Deviation from Standard Operating Procedure Requisition – Incorrect Results – Delayed Results – Incorrect Reading Results – Posted to Wrong Patient Test – Cancelled Test – Delayed Test – Inappropriate Test – Incomplete Test – Incorrect Test – Incorrectly Performed Test – Not Ordered Test – Ordered, Not Performed Test – Scheduled Delay Test – Wrong Procedure Test – Wrong Side (L vs R) Test – Wrong Site Equipment/Medical Device Bed Malfunction Broken Item Disconnected Electrical Equipment – Damaged/Faulty/Worn Equipment – Malfunction Equipment – Misuse Equipment – Not Available Equipment – Other Issue Equipment – Wrong or Inadequate Failed Test of Standard Procedures Inadequate Supplies Medical Device Issue Other Outdated Item Preventative Maintenance Inadequate/Not Performed Sterilization/Cleanliness Facilities Air Quality Boarding patient more than six (BHU patient) Boarding patient more than six hours (Non-BHU patient) Cleanliness of Facility Communications Down Elevator Malfunction Equipment Issue Other Patients receiving care in area not designated for care Spill – Radiation Temperature of Facility Use of unlicensed beds for patient care Water Leak/Flood Fall From Bed – Lying in Bed From Bed – Sitting on the Side From Chair From Exam Stool From Exam/Operating Table From Stretcher From Toilet/Commode From Wheelchair In Hallway On Grounds of Facility Other on Floor While Ambulating Infection Hand Hygiene Compliance Issue Isolation – Breach Isolation – Failure to Follow Protocol Other Patient Exposure – Blood/Body Fluid Patient Exposure – Communicable Disease Patient Exposure – Contaminated Material Patient Exposure – Sharps Issue Single-Use Item Submitted for Reprocessing Sterilization/Disinfection Issue Suspected Infection
Testing Issue – Wrong Test Performed Line/Tube Disconnected Discontinued Incorrectly Dislodgement Maternal/Childbirth Apgar Score < 5 at 5 Min Birth Trauma DVT (Deep Vein Thrombosis) Fetal Death in Labor Intrapartum Death Maternal – Death Maternal – Infection Maternal – Other Neonatal – Death Neonatal – Other Other Pulmonary Embolism RN Attended Birth Seizure Within First 24 Hrs of Birth Shoulder Dystocia Unanticipated Transfusion Undiagnosed/Untreated Hyperbilirubinemia Unexpected Transfer to ICU Unexpected Transfer to NICU Uterine Rupture Medication/Fluid Administration Technique Incorrect Contraindicated – Drug-Disease Contraindicated – Drug-Drug Contraindicated – Drug-Food Contraindicated – Known Allergy Contraindicated – Dose Incorrect – Dosage Form Dose Incorrect – Extra Dose Dose Incorrect – Omitted Dose Incorrect – Overdose Dose Incorrect – Underdose Dose Incorrect – Unknown Dose Med – Contaminated Med – Deteriorated Med – Expired Med – Incorrect Med – Unauthorized Med Process – Dispensing Incorrect Med Process – Disposal Inappropriate Med Process – Med Not Ordered Med Process – Medication List Incorrect Med Process – Narcotic Discrepancy Med Process – Order Incorrect Med Process – Prescription/Refill Med Timing – Duration Incorrect Med Timing – Frequency Wrong Med Timing – Incorrect Monitoring – Error (Lab Value, Vital Sign) Monitoring – Failure To Monitoring – Other Pain Management Inadequate Patient – Incorrect Quantity Incorrect Rate Incorrect Route Incorrect Site Incorrect Storage Incorrect Strength/Concentration – Incorrect Patient ID/Documentation/Consent Armband – Absent Armband – Wrong DOB Armband – Name Armband – Patient Consent – None Consent – Unsigned/Incomplete Consent – Wrong Procedure Listed Consent – Wrong Side/Site Listed Date of Birth – Incorrect Date of Birth – Mssing DNR - Wristband Documentation – Incorrect Documentation – Missing Fax Event – Document Faxed to Wrong Number HIPAA Privacy Incident Other Scan – Document Scanned to Wrong EMR Task Event – Task Entered on Wrong EMR Task Event – Task Sent to Wrong Provider/Office Provision of Care Admission Issue AMA Cardiopulmonary Arrest Outside of ICU Setting Complication Following Spinal Manipulative Therapy Delay/Failure to Monitor Alarm Setting/Function of Communication of Critical Data