Table 3 Types of unintended events
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 |  |