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Table 1 Classification criteria for systems failures and practitioner-based errors identified by the PRC

From: Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process

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