Table 1

Examples of patient safety events, severity of events, and organizational outcomes in an Emergency Medicine residency.

Example Event TypeSeverityOrganizational Outcome
Diagnostic Imaging-Patient Taken to CT without Proper CommunicationUnsafe ConditionPatient Hand-Off Document Developed for all Patients Leaving the Emergency Department
Lab/Specimen-Results Issue Involving Point of Care Testing (i-STAT)Unsafe ConditionQuality Control Completed. Cartridges Collected and Returned to Manufacturer for Investigation.
Medication/Fluid-Incorrect Medication Available in FormularyUnsafe ConditionOption Inactivated
Diagnostic Imaging-Ordered and Completed on Incorrect PatientNo Harm-Reached PatientIdentified Trend: 10% of Reported Diagnostic Imaging Safety Events Involve an Incorrect Patient
Lab/Specimen-Results Issue Involving Point of Care Testing (i-STAT)No Harm-Reached PatientEducation Material Developed for Emergency Department Physicians and Staff Regarding i-STAT Limitations
Airway Management-Delayed IntubationHarm-Temporary Intervention NeededImmediate: “Airway Box” Placed on Inpatient Rehab Crash Cart. In Progress: Patient Safety Debriefing and Proactive Risk Assessment