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

Table 3 Systems failures and practitioner-based errors identified in cases of patient harm

Case	Patient harm	System failures and practitioner-based errors contributing to harm
1	Death	ED teamwork, major cognitive error
2	Death	ED teamwork, hospital teamwork, boarded patient, major cognitive error
3	Permanent harm	ED teamwork, hospital teamwork, major cognitive error
4	Temporary harm	ED teamwork, cognitive error
5	Temporary harm	ED teamwork, hospital teamwork, cognitive error
6	Temporary harm	ED work environment, cognitive error
7	Temporary harm	Cognitive error
8	Temporary harm	ED teamwork, hospital teamwork, major cognitive error
9	Temporary harm	ED teamwork, boarded patient
10	Temporary harm	ED teamwork, hospital teamwork, major cognitive error
11	Temporary harm	ED teamwork, Hospital work environment
12	Temporary harm	Hospital teamwork

ISSN: 1471-227X