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

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

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