Table 2

Triggers, adverse events (AEs) and harm

Triggers and events by patient encounter
Trigger	Trigger type/group	Triggers		Potential harm		Confirmed harm		Combined AEs
Trigger	Trigger type/group	Total	%	Total	%	Total	%	Total	%
T1	Documentation errors	436	49.4	25	3.1	0	0.0	25	3.1
T2–T4	Operational/patient movement triggers	24	2.7	11	1.4	2	0.2	13	1.6
T2	Prolonged scene time*	21	2.4	10	1.2	2	0.2	12	1.5
T3	Injury to patient or self during care	0	0.0	0	0.0	0	0.0	0	0.0
T4	Request for additional resources	3	0.3	1	0.1	0	0.0	1	0.1
T5–T6	Patient condition triggers	67	7.6	14	1.7	10	1.2	24	3.0
T5	Worsening trend in vitals	52	5.9	14	1.7	6	0.7	20	2.5
T6	Cardiac arrest during transport	15	1.7	0	0.0	4	0.5	4	0.5
T7–T11	Intervention and medication triggers	356	40.3	145	18.0	16	2.0	161	20.0
T7	High-risk interventions	79	8.9	7	0.9	1	0.1	8	1.0
T8	Failed interventions*	35	4.0	20	2.5	1	0.1	21	2.6
T9	Use of high-risk medication	71	8.0	2	0.2	1	0.1	3	0.4
T10	Deviation from standard of care*	140	15.9	90	11.2	11	1.4	101	12.6
T11	Medication errors	31	3.5	26	3.2	2	0.2	28	3.5
Total		883	100.0†	195	24.3	28	3.5	223	27.7
Proportions as % of patients
T1	Documentation errors	436	81.2	25	15.8	0	0.0	25	14.9
T2	Prolonged scene time*	21	3.9	10	6.3	2	14.0	12	7.1
T3	Injury to patient or self during care	0	0.0	0	0.0	0	0.0	0	0.0
T4	Request for additional resources	3	0.6	1	0.6	0	0.0	1	0.6
T5	Worsening trend in vitals	52	9.7	14	8.9	6	43.0	20	11.9
T6	Cardiac arrest during transport	15	2.8	0	0.0	4	29.0	4	2.4
T7	High-risk interventions	79	14.7	7	4.4	1	7.0	8	4.8
T8	Failed interventions*	35	6.5	20	12.7	1	7.0	21	12.5
T9	Use of high-risk medication	71	13.2	2	1.3	1	7.0	3	1.8
T10	Deviation from standard of care*	140	26.1	90	57.0	11	79.0	101	60.1
T11	Medication errors	31	5.8	26	16.5	2	14.0	28	16.7
Total		536	100.0	158	100.0	14	100.0	168	100.0
Proportions as % of AEs
T1	Documentation errors	25	11.2	25	12.9	0	0.0	25	11.2
T2–T4	Operational/patient movement triggers	13	5.8	11	5.7	2	6.9	13	5.8
T2	Prolonged scene time*	12	5.4	10	5.2	2	6.9	12	5.4
T3	Injury to patient or self during care	0	0.0	0	0.0	0	0.0	0	0.0
T4	Request for additional resources	1	0.4	1	0.5	0	0.0	1	0.4
T5–T6	Patient condition triggers	24	10.8	14	7.2	10	34.5	24	10.8
T5	Worsening trend in vitals	20	9.0	14	7.2	6	20.7	20	9.0
T6	Cardiac arrest during transport	4	1.8	0	0.0	4	13.8	4	1.8
T7–T11	Intervention and medication triggers	161	72.2	145	74.3	16	57.1	161	72.2
T7	High-risk interventions	8	3.6	7	3.6	1	3.4	8	3.6
T8	Failed interventions*	21	9.4	20	10.3	1	3.4	21	9.4
T9	Use of high-risk medication	3	1.3	2	1.0	1	3.5	3	1.3
T10	Deviation from standard of care*	101	45.3	90	46.4	11	37.9	101	45.3
T11	Medication errors	28	12.6	26	13.4	2	6.9	28	12.6
Total		223	100.0	195	100.0	28	100.0	223	100.0

Denominator=804 (triggers and events by patient encounter); denominator=536 (proportions as % of patients); denominator=223 (proportions as % of AEs); denominator=195 (potential harm), 28 (harm), 223 (combined AEs).
*As defined by the PittAETool and in accordance with HMCAS Standard Operating Procedures, guidelines and norms.
†Denominator=883 (trigger events), where 37.3% of patients who triggered had 2 or more triggers (n=200).
HMCAS, Hamad Medical Corporation Ambulance Service; PittAETool, Pittsburgh Adverse Event Tool.