From: The nature and causes of unintended events reported at ten emergency departments
Unintended event type |
No. of unintended events (%) (N = 522) |
---|---|
Collaboration with other departments | 128 (24.5) |
e.g. long waiting time for laboratory test results | |
e.g. not al requested X-rays made at radiology department | |
e.g. difficulties finding a place at a nursing ward for the patient | |
Materials and equipment | 106 (20.3) |
e.g. ear thermometer gives inaccurate measurements | |
e.g. error in electronic record system (unable to look up medical history of patient) | |
e.g. materials lacking for treatment of patient | |
Collaboration with resident physicians and consultants | 89 (17.0) |
e.g. long waiting time for resident or consultant to come | |
e.g. insufficient supervision of resident physicians | |
e.g. not able to reach resident or consultant | |
Diagnosis and treatment | 75 (14.4) |
e.g. no plaster bandage applied after fracture reposition | |
e.g. eyelid glued when gluing nose bridge | |
e.g. elbow injury overlooked | |
Incorrect data and substitutions | 39 (7.5) |
e.g. incorrect date on X-ray | |
e.g. appointment form given to wrong patient | |
e.g. sticker with personal information of wrong patient pasted on laboratory request form | |
Medication | 38 (7.3) |
e.g. prescription of medicine in incorrect dose | |
e.g. medication expired | |
e.g. medication instruction accomplished twice | |
Protocols and regulations | 20 (3.8) |
e.g. inconsistency in protocols | |
e.g. protocol untraceable on the intranet | |
e.g. staff not familiar with procedure in new protocol | |
Other | 27 (5.2) |
e.g. inadequate transport of patient | |
e.g. dangerous ground sill at entrance of ED | |
e.g. patient leaves hospital without being discharged |