Adverse Drug Reaction Blood Product Allergy Unknown to Patient Adverse Reaction Drug Disease Interaction Computer Issue Result Entry Error – – Drug Drug Interaction Consent Issue – Drug Food Interaction Incorrect Volume (i.e., # of Units or – Other Milliliters) Other Airway Management Patient Incorrectly Collected – Patient Requested – Airway Mgmt Equipment Issue Patient Transfused – Airway Obstructed Patient ID Issue Missing BB Armband – Delivery Mode Incorrect Patient ID Issue Missing/Incorrect Info – Extubation Self – on BB Armband Extubation Unplanned – Process Administration – Intubation Unplanned – Process Component Modification – Medical Gas Problem Process Deviation From Standard – Missed Treatment Operating Procedure Other Process Dispensing/Distribution – Rate/Flow/Concentration Incorrect Re-Intubation Required – Process Patient Requested – Respiratory Mgmt Delayed – Product Expired – Respiratory Mgmt Inappropriate – Product Incorrect Storage (Out of – Ventilator Alarms Inaudible – Bank) Ventilator Alarms Not Set Properly – Product Inventory Issue – Ventilator Settings Changed – Product Unit Thawed not Transfused – Without Authorization Product Wasted – Ventilator Settings Wrong – Product Blood Product – Transfused Behavioral Product Wrong Component Issued – Abuse/Assault (Physical) Product Wrong Component – Abuse/Assault (Verbal) Requested Alleged Sexual Encounter Special Product Need Not Issued BHU Best Practice Diversion Special Product Need Not Requested Bite (Human) Specimen Collection Drawn Too Soon – Death involving restraints Specimen Collection Issue Death involving seclusion Specimen Labeling Missing/Incorrect – Death or injury during inpatient Info on Label elopement Specimen Labeling No Barcode BB – Eloped ID# Sticker Eloped Attempted/Out of Bounds Transfusion Issue – Eloped (left without notice) during 302 Transfusion Issue Acceptable Time – – process Frame/Expired Eloped (left without notice) not in 302 – Unit Mismatched process User Error Inappropriate use of restraint/seclusion Diagnosis/Treatment Injury involving restraints Injury involving seclusion Adverse Reaction (Non Med) Ligature attempt Diagnosis Delayed – Diagnosis Incorrect – Possession of contraband Diagnosis Missed – Restraint/Seclusion Duration Past Failure to Assess Patient Allowed Limit Isolation Failure to Follow Protocol – Self-Harm Other Suicide attempt Treatment Delayed – Suicide completed Treatment Inappropriate – Wrongful conduct Treatment Incorrectly Performed –
Adverse Drug Reaction Allergy Unknown to Patient Drug – Disease Interaction Drug – Drug Interaction Drug – Food Interaction Other Airway Management Airway Mgmt Equipment Issue Airway Obstructed Delivery Mode Incorrect Extubation – Self Extubation – Unplanned Intubation – Unplanned Medical Gas Problem Missed Treatment Other Rate/Flow/Concentration Incorrect Re-Intubation – Required Respiratory Mgmt – Delayed Respiratory Mgmt – Inappropriate Ventilator – Alarms Inaudible Ventilator – Alarms Not Set Properly Ventilator – Settings Changed Without Authorization Ventilator – Settings Wrong Behavioral Abuse/Assault (Physical) Abuse/Assault (Verbal) Alleged Sexual Encounter BHU Best Practice Diversion Bite (Human) Death involving restraints Death involving seclusion Death or injury during inpatient elopement Eloped Eloped – Attempted/Out of Bounds Eloped (left without notice) – during 302 process Eloped (left without notice) – not in 302 process Inappropriate use of restraint/seclusion Injury involving restraints Injury involving seclusion Ligature attempt Possession of contraband Restraint/Seclusion Duration Past Allowed Limit Self-Harm Suicide attempt Suicide completed Wrongful conduct Blood Product Adverse Reaction Computer Issue – Result Entry Error Consent Issue Incorrect Volume (i.e., # of Units or Milliliters) Other Patient – Incorrectly Collected Patient – Requested Patient – Transfused Patient ID Issue – Missing BB Armband Patient ID Issue – Missing/Incorrect Info on BB Armband Process – Administration Process – Component Modification Process – Deviation From Standard Operating Procedure Process – Dispensing/Distribution Process – Patient Requested Product – Expired Product – Incorrect Storage (Out of Bank) Product – Inventory Issue Product – Unit Thawed not Transfused Product – Wasted Product – Blood Product Transfused Product – Wrong Component Issued Product – Wrong Component Requested Special Product Need Not Issued Special Product Need Not Requested Specimen Collection – Drawn Too Soon Specimen Collection Issue Specimen Labeling – Missing/Incorrect Info on Label Specimen Labeling – No Barcode BB ID# Sticker Transfusion Issue Transfusion Issue – Acceptable Time Frame/Expired Unit Mismatched User Error Diagnosis/Treatment Adverse Reaction (Non Med) Diagnosis – Delayed Diagnosis – Incorrect Diagnosis – Missed Failure to Assess Patient Isolation – Failure to Follow Protocol Other Treatment – Delayed Treatment – Inappropriate Treatment – Incorrectly Performed