Examples of patient safety events, severity of events, and organizational outcomes in an Emergency Medicine residency.
| Example Event Type | Severity | Organizational Outcome |
|---|---|---|
| Diagnostic Imaging-Patient Taken to CT without Proper Communication | Unsafe Condition | Patient Hand-Off Document Developed for all Patients Leaving the Emergency Department |
| Lab/Specimen-Results Issue Involving Point of Care Testing (i-STAT) | Unsafe Condition | Quality Control Completed. Cartridges Collected and Returned to Manufacturer for Investigation. |
| Medication/Fluid-Incorrect Medication Available in Formulary | Unsafe Condition | Option Inactivated |
| Diagnostic Imaging-Ordered and Completed on Incorrect Patient | No Harm-Reached Patient | Identified 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 Patient | Education Material Developed for Emergency Department Physicians and Staff Regarding i-STAT Limitations |
| Airway Management-Delayed Intubation | Harm-Temporary Intervention Needed | Immediate: “Airway Box” Placed on Inpatient Rehab Crash Cart. In Progress: Patient Safety Debriefing and Proactive Risk Assessment |