Postintervention (May 2013–2017): 7 PSAs total
2	Lack of proper medical workup before procedure.
2	ESWL consent placed in wrong chart and urology chart missing with ESWL consent.
1	Gastroenterologist late delaying ESWL.
1	Inpatient scheduled by hospitalist with no communication with GI department.
1	Lithotripter table double booked due to scheduler error, ESWL delay.

ERCP, endoscopic retrograde cholangiopancreatography; ESWL, extracorporeal shock wave lithotripsy.