Table 2 Trigger origin for cases containing adverse events (AE)
From: Adverse events in prehospital emergency care: a trigger tool study
Trigger | Triggers (n) | Triggers related to potential for harm (AE 1) (n (% (95% CI)) | Triggers related to harm identified (AE 2) (n (% (95% CI)) |
|---|---|---|---|
T1: Missing, incomplete, or unclear documentation | 652 | 35 (5.4 (3.9–7.6)) | 3 (0.5 (0.1–1.5)) |
T2: Time from initial patient contact to transfer of care exceeds accepted standards. | 47 | 8 (17.0 (8.1–31.3)) | 1 (2.1 (0.1–12.7)) |
T3: Injury to patient or team member during patient encounter/transport | 1 | 0 (0 (0–0)) | 0 (0 (0–0)) |
T4: Request for additional resources, personnel, or supervisor due to change in patient condition | 3 | 0 (0 (0–0)) | 0 (0 (0–0)) |
T5: A worsening trend in patient hemodynamic or mental status indicators | 7 | 1 (14.3 (0.7–58.0)) | 1 (14.3 (0.7–58.0)) |
T6: Cardiac arrest during transport | 4 | 0 (0 (0–0)) | 1 (25.0 (1.3–78.1)) |
T7: Use of any of the following interventions: cardioversion, defibrillation, transcutaneous pacing, advanced airway attempt, surgical airway, intraosseous access, chest decompression, chest tube | 7 | 1 (14.3 (0.7–58.0)) | 0 (0 (0–0)) |
T8: Failure of any intervention or procedure during patient care | 9 | 2 (22.2 (3.9–59.8)) | 1 (11.1 (0.6–49.3)) |
T9: Use of following medications or fluids: blood products, vasopressors or inotropes, naloxone | 10 | 1 (10 (0.5–45.9)) | 0 (0 (0–0)) |
T 10: Evidence suggestive of deviation from standard of care by performing an intervention or administering a medication that appears to be outside protocol or failure to perform an intervention or provide a medication that is within the standard of care | 305 | 37 (12.1 (8.8–16.6)) | 3 (1.0 (0.3–3.1)) |
T 11: Medication error | 24 | 4 (16.7 (5.5–38.2)) | 1 (4.2 (0.2–23.1)) |