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