Home - WellSpan Health



Adverse Drug ReactionAllergy Unknown to PatientDrug – Disease InteractionDrug – Drug InteractionDrug – Food InteractionFlumazenil AdministrationNaloxone AdministrationOther Airway ManagementAirway Mgmt Equipment IssueAirway ObstructedDelivery Mode IncorrectExtubation – SelfExtubation – UnplannedIntubation – UnplannedMedical Gas ProblemMissed TreatmentOtherRate/Flow/Concentration IncorrectRe-Intubation – RequiredRespiratory Mgmt – DelayedRespiratory Mgmt – InappropriateVentilator – Alarms InaudibleVentilator – Alarms Not Set ProperlyVentilator – Settings Changed Without AuthorizationVentilator – Settings WrongBehavioralAbuse/Assault (Physical)Abuse/Assault (Verbal)Alleged Sexual EncounterAMABHU Best Practice DiversionBite (Human)Death involving restraintsDeath involving seclusionDeath or injury during inpatient elopementElopedEloped – Attempted/Out of BoundsEloped (left without notice) – during 302 processEloped (left without notice) – not in 302 processInappropriate use of restraint/seclusionInjury involving restraintsInjury involving seclusionLigature attemptOtherPossession of contrabandRestraint/Seclusion Duration Past Allowed LimitSelf-HarmSuicide attemptSuicide completedWrongful conductBlood ProductAdverse ReactionComputer Issue – Result Entry ErrorConsent IssueFFP Ordering ProcessIncorrect Volume (i.e., # of Units or Milliliters)OtherPatient – Incorrectly CollectedPatient – Wrong RequestedPatient – Wrong TransfusedPatient ID Issue – Missing BB ArmbandPatient ID Issue – Missing/Incorrect Info on BB ArmbandProcess – Administration IssueProcess – Component Modification Process – Deviation From Standard Operating Procedure Process – Dispensing/Distribution IssueProcess – Wrong Patient RequestedProduct – ExpiredProduct – Incorrect Storage (Out of Bank)Product – Unit Thawed not TransfusedProduct – WastedProduct – Wrong Component IssuedProduct – Wrong Component RequestedSpecial Product Need Not IssuedSpecial Product Need Not RequestedSpecimen Collection – Drawn Too SoonSpecimen Collection – Scan Scan DeviationSpecimen Collection IssueSpecimen Labeling – Missing/Incorrect Info on LabelSpecimen Labeling – No Barcode BB ID# StickerTransfusion IssueTransfusion Issue – Acceptable Time Frame/ExpiredType and Screen Epic Ordering IssueUnit MismatchedUser ErrorDiagnosis/TreatmentAdverse Reaction (Non Med)Diagnosis – DelayedDiagnosis – IncorrectDiagnosis – MissedFailure to Assess PatientIsolation – Failure to Follow ProtocolOtherRadiation Oncology – Radiation PrescriptionRadiation Oncology – Therapeutic Radiation IncidentRadiation Oncology – Treatment PlanTreatment – DelayedTreatment – InappropriateTreatment – Incorrectly PerformedTreatment – No Order ForTreatment – Wrong PatientUnexpected Cardiac and/or Respiratory Arrest Requiring ACLS Intervention Diagnostic Imaging Contrast – Allergic ReactionContrast – ExtravasationEquipment – Failure/MalfunctionEquipment – Maintenance IssueExposure – OverexposureExposure – Prolonged FluoroExposure – Unanticipated Radiation ExposureFilm Unavailable or InadequateImage – IncorrectInfiltration EventMRI Safety IssueOtherProcess – Deviation from Standard Operating ProcedureRequisition – IncorrectResults – DelayedResults – Incorrect ReadingResults – Posted to Wrong PatientTest – CancelledTest – DelayedTest – InappropriateTest – IncompleteTest – IncorrectTest – Incorrectly PerformedTest – Not OrderedTest – Ordered, Not PerformedTest – Scheduled DelayTest – Wrong ProcedureTest – Wrong Side (L vs R)Test – Wrong SiteEmployee Health and SafetyBlood/Bodily Fluid/Needle Stick ExposureEnvironmental/Occupational Safety incident or issueWorkers Comp – work related illness/injuryWorkplace ViolenceEquipment/Medical DeviceBed MalfunctionBroken ItemDisconnectedElectrical IssueEquipment – Damaged/Faulty/WornEquipment – MalfunctionEquipment – MisuseEquipment – Not AvailableEquipment – Wrong or InadequateFailed Test of Standard ProceduresInadequate SuppliesMedical Device IssueOtherOutdated ItemPreventative Maintenance Inadequate/Not PerformedSterilization/Cleanliness Issue FacilitiesAir QualityBoarding patient more than six hours (BHU patient)Boarding patient more than six hours (Non-BHU patient)Cleanliness of FacilityCommunications DownDisaster – ExternalDisaster – Internal Elevator Malfunction Equipment IssueOtherPatients receiving care in area not designated for careSpill – RadiationTemperature of FacilityUse of unlicensed beds for patient careWater Leak/FloodFall From Bed – Lying in BedFrom Bed – Sitting on the SideFrom Exam StoolFrom Exam/Operating TableFrom StretcherFrom Toilet/CommodeFrom WheelchairIn HallwayOn Grounds of FacilityOtherUnknown/Found on FloorWhile Ambulating InfectionHand Hygiene Compliance IssueIsolation – BreachIsolation – Failure to Follow ProtocolOtherPatient Exposure – Blood/Body FluidPatient Exposure – Communicable DiseasePatient Exposure – Other Contaminated MaterialPatient Exposure – Sharps IssueSingle-Use Item Submitted for ReprocessingSSI, not meeting NHSN criteriaSterilization/Disinfection IssueIV/Vascular Access DeviceCirculation ImpededDisconnectedDiscontinued IncorrectlyDiscontinued Without OrderDislodgementInfiltration/ExtravasationLine Not ChangedLocalized ReactionOcclusionOtherPhlebitisSeveredWrong Insertion LocationWrong Size Inserted Lab/SpecimenCollection Issue – DelayedCollection Issue – Equipment FailureCollection Issue – HematomaCollection Issue – Incorrect Collection SiteCollection Issue – Needle Left in BedCollection Issue – Tourniquet Left OnCollection Issue – Wrong PatientLabeling Issue – Incorrect/Missing Info on LabelLabeling Issue – Label and Requisition MismatchLabeling Issue – Specimen MislabeledLabeling Issue – Specimen UnlabeledOrdering Issue – Missed TestOrdering Issue – Missing Clinical InfoOrdering Issue – No Order or RequisitionOrdering Issue – Ordered at Wrong TimeOrdering Issue – Requisition IncompleteOrdering Issue – Requisition IncorrectOrdering Issue – Wrong EncounterOrdering Issue – Wrong Ordering PhysicianOrdering Issue – Wrong PatientOrdering Issue – Wrong PriorityOrdering Issue – Wrong Test OrderedOtherPatient ID Issue – DOB Incorrect on Wristband/Requisition Reporting Issue – Critical Value Not CalledReporting Issue – Delayed Report (Results Available)Reporting Issue – Significant Finding Not CalledResults – Called to Wrong PhysicianResults – DelayedResults – IncorrectResults – Posted to Wrong PatientResults – UncommentedSpecimen Acceptability – Contamination Specimen Acceptability – HemolyzedSpecimen Acceptability – InterferenceSpecimen Acceptability – None in ContainerSpecimen Acceptability – Not Received on IceSpecimen Acceptability – Preservative IssueSpecimen Acceptability – QNSSpecimen Acceptability – Unable to TestSpecimen Acceptability – Wrong ContainerSpecimen Acceptability – Wrong SpecimenSpecimen Processing – DelaySpecimen Processing – Delivery ProblemSpecimen Processing – Microbiology Processing ErrorSpecimen Processing – Pneumatic Tube ErrorSpecimen Processing – Received in ErrorSpecimen Processing – Specimen DestroyedSpecimen Processing – Specimen MisplacedSpecimen Processing – Specimen Not Processed CorrectlySpecimen Processing – Specimen Not Shared Between DepartmentsSpecimen Processing – Specimen Storage Requirements Not MetTesting Issue – Delay in TestingTesting Issue – Equipment Performance IssueTesting Issue – Quality Control IssueTesting Issue – Test Not PerformedTesting Issue – Test Performed IncorrectlyTesting Issue – Test Result Incorrect (Analytical)Testing Issue – Test Result Incorrect (Clerical)Testing Issue – Wrong Test Performed Line/TubeDisconnectedDiscontinued IncorrectlyDislodgementOther Wrong size insertedMaternal/ChildbirthApgar Score < 5 at 5 MinBirth TraumaDVT (Deep Vein Thrombosis)Intrapartum Fetal DeathMaternal – DeathMaternal – InfectionMaternal – OtherNeonatal – DeathNeonatal – OtherOtherPulmonary EmbolismRN Attended BirthSeizure Within First 24 Hrs of BirthShoulder DystociaStillborn/Fetal Death in LaborUnanticipated Blood TransfusionUndiagnosed/Untreated HyperbilirubinemiaUnexpected Transfer to ICUUnexpected Transfer to NICUUterine RuptureMedication/FluidAdministration Technique Incorrect Contraindicated – Drug-DiseaseContraindicated – Drug-DrugContraindicated – Drug-FoodContraindicated – Known AllergyContraindicated – OtherDose Incorrect – Dosage FormDose Incorrect – Extra DoseDose Incorrect – OmittedDose Incorrect – OverdoseDose Incorrect – UnderdoseDose Incorrect – Unknown DoseDuplicate therapy/ordersMed – ContaminatedMed – DeterioratedMed – ExpiredMed – IncorrectMed – UnauthorizedMed Process – Dispensing Label/Instruction IncorrectMed Process – Disposal InappropriateMed Process – Med Not OrderedMed Process – Medication List IncorrectMed Process – Narcotic DiscrepancyMed Process – Order IncorrectMed Timing – Duration IncorrectMed Timing – Frequency WrongMed Timing – IncorrectMonitoring – Error (Lab Value, Vital Sign)Monitoring – OtherOther Pain Management InadequatePatient – IncorrectQuantity Incorrect Rate IncorrectRoute IncorrectSite IncorrectStorage IncorrectStrength/Concentration – IncorrectPatient ID/Documentation/ConsentArmband – AbsentArmband – Wrong DOBArmband – Wrong NameArmband – Wrong PatientConsent – None Consent – Unsigned/IncompleteConsent – Wrong Procedure ListedConsent – Wrong Side/Site ListedDate of Birth – IncorrectDate of Birth – MssingDNR – WristbandDocumentation – IncorrectDocumentation - MissingFax Event – Document Faxed to Wrong NumberHIPAA Privacy IncidentOtherScan Event – Document Scanned to Wrong EMRTask Event – Task Entered on Wrong EMRTask Event – Task Sent to Wrong Provider/OfficeProvision of CareAdmission IssueCardiopulmonary Arrest Outside of ICU SettingComplication Following Spinal Manipulative Therapy Delay/Failure to Monitor Alarm Setting/FunctionDelay/Lack of Communication of Critical DataDelay/Lack of Response to Patient ConditionDietary – Foreign Body in FoodDietary – Incorrect DietDietary – NPO Patient Given FoodDietary – OtherDietary – Patient Allergy to DietDischarge IssueDisruptive BehaviorED – Discrepancy Betw ED Interpretation of Xray or EKG and Final ReadingED – Unplanned Return in 48 Hrs Requiring AdmissionElectric Shock to PatientFailure to Follow OrderFailure to Obtain Appropriate AssistanceFailure to Respond to Request for Service Handoff IssueInappropriate DischargeInfant/Child AbductionInfant/Child Discharged to Wrong PersonOnset of Hypoglycemia During CareOtherPatient Death (Unexpected)Rapid Response Team initiated Referral – Delay in SchedulingReferral – Delay in ServiceReferral – OtherReferral – Report Unavailable or DelayedTimeliness of Response to OrderTOC Post DischargeTransition of care medication discrepancyUnanticipated Transfer to Higher Level of CareSafety and SecurityAbandonmentAbductionAuto AccidentChemical SpillDisorderly PersonDomestic QuarrelDrug Diversion – ActualDrug Diversion - PotentialEntrapmentEquipment MalfunctionEvidence/Contraband Collection (for chain of custody)Fire/Fire AlarmHospital in Divert StatusLaw Enforcement AssistLost Health Record/ChartMissing/Wandering Patient/ResidentOtherProperty Damage/VandalismProperty LostSafety Policy ViolationSmokingTheft/Suspected TheftThreat of ViolenceUnauthorized Access/TrespassingUnauthorized DrugsUnauthorized EquipmentUnauthorized PersonWeapons on PremisesSkin/TissueAbrasionBlisterBruiseBurn – ChemicalBurn – ElectricalBurn – ThermalDehiscence/EviscerationDiabetic UlcersDiaper DermatitisFriction/ShearLacerationOtherPressure InjuryPunctureRash/HivesSkin Tear/CutStasis UlcersSurgery/ProcedureBreak in Sterile TechniqueCardiac Arrest During ProcedureCardiac or Circulatory EventCentral Nervous System EventComplications of AnesthesiaComplications of Surgery/ProcedureConsent IssueContaminationCount Discrepancy – InstrumentCount Discrepancy – NeedleCount Discrepancy – OtherCount Discrepancy – SpongeCount Incomplete/Not PerformedForeign Object Retained Post ProcedureID Missing/IncorrectImplant – Not AvailableLaceration/PunctureOmission of ProcedureOperating Room FireOtherPost-Operative AMI (Unrelated to a Cardiac Procedure)Preparation IncorrectProcedure – DelayedProcedure – Delayed, Pt Under AnesthesiaProcedure – Incorrect Procedure PerformedProcedure – Not CompletedProcedure – Not OrderedProcedure – Performed IncorrectlyRenal Failure, Impairment or InsufficiencySurgical Site Not MarkedTissue Trauma From ProcedureUnexpected Intra-Operative DeathUnexpected Post-Operative DeathUnexpected Return to the ORUnplanned Admit to ICUWrong Side Wrong Site (L vs R) ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download