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Systems failures
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Triage
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A failure in assessment of potential disease severity during triage
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Abnormal vital signs not recognized as a potential sign of shock
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ED teamwork
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A failure due to an issue with ED staff communication or a shared responsibility across multiple ED staff
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Change in vital signs not communicated to the attending physician
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Hospital Teamwork
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A failure due to an issue with communication between ED and hospital staff or a shared responsibility between the ED and hospital staff
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Pertinent information not communicated to the admitting team
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ED work environment
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A failure resulting from the lack, malfunction, or mal-design of resources, equipment, or physical space within the ED or a failure due to not following an ED policy or clinical practice guideline
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Missing equipment
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Hospital work environment
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A failure resulting from the lack, malfunction, or mal-design of resources, equipment, or physical plant outside the ED but still within the hospital or a failure due to not following a hospital policy or clinical practice guideline
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Specialty testing areas remotely located from the ED
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Boarded patient
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A failure occurring after a patient is admitted to an in-patient service but is still physically located in the ED
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N/A
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Practitioner-based errors
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Major cognitive error
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An error which represents serious mismanagement in a knowledge area basic to EM
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Failure to diagnose or treat ST-elevation myocardial infarction
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Cognitive error
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An error which represents mismanagement which is either less serious than a major cognitive error or in an area less basic to EM
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Failure to consider the institutional antibiogram during antibiotic selection for treatment of simple urinary tract infection
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Missed radiographic finding
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An error in interpretation of a radiographic study that did not reach the level of a cognitive or major cognitive error
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Missed fracture on radiographic interpretation that was splinted correctly based on clinical suspicion
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Policy deviation
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An error in following a clinical or administrative policy, guideline or standard practice that does not reach the level of cognitive or major cognitive error
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Failure to alert the transplant service when a transplant patient is in the ED
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Procedural error
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A technical error during performance of a procedure that does not reach the level of a cognitive or major cognitive error
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Insufficient sterile technique
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