3. Airway: Self Extubation 27. Equipment: Failure 4. AMA/Elopement 28. Equipment: Unavailable 6 5. Blood Bank: Other Issues 29. Fall 6. Blood Bank: Transfusion issue 30. Hemorrhage Control 7. Blood Bank: Availability/Massive 31. Hypothermia: Inappropriate assessment Transfusion 32. Hypothermia: Inappropriate warming 8. Burn Care Issues measures 9. Case Management: Other 33. Immobilization: Inappropriate or inadequate 10. Case Management: Insurance Issue 34. Inappropriate transfer to Floor/ICU 11. Communication: Interdisciplinary 35. Inappropriate use of CT 12. Communication: Lack of appropriate patient/family communication 36. Infection: Central Line 13. Communication: Lack of documentation 37. Infection: Nosocomial (Other) 14. Communication: Lack of Social Worker 38. Missed Diagnosis Involvement 39. Monitoring: Inappropriate 15. Consultant: Delay in Evaluation 40. Nursing: Delay in notification of patient 16. Consultant: Delay in Treatment event 17. Delay: Completion of work-up 41. Nursing: Documentation issue 18. Delay: Diagnosis 42. Nursing: Medication issue 19. Delay: Diagnostic studies 43. Nursing: Transfusion Issue – Removed. 20. Delay: Subspecialty consultation 44. Nutrition issues 21. Delay: Physical Therapy/Rehabilitation 45. OR Delay: Other 22. Delay: Trauma team arrival 46. OR Delay: Anesthesia Related 23. Delay: Trauma team notification 47. OR Delay: Availability 24. Delay: Treatment 48. OR Delay: Resuscitation 25. Delay: Discharge 49. OR Delay: Transportation – Removed 26. DVT/PE Prophylaxis: Inappropriate 50. Organ Procurement Issues
3. Airway: Self Extubation 4. AMA/Elopement 5. Blood Bank: Other Issues 6. Blood Bank: Transfusion issue 7. Blood Bank: Availability/Massive Transfusion 8. Burn Care Issues 9. Case Management: Other 10. Case Management: Insurance Issue 11. Communication: Interdisciplinary 12. Communication: Lack of appropriate patient/family communication 13. Communication: Lack of documentation 14. Communication: Lack of Social Worker Involvement 15. Consultant: Delay in Evaluation 16. Consultant: Delay in Treatment 17. Delay: Completion of work-up 18. Delay: Diagnosis 19. Delay: Diagnostic studies 20. Delay: Subspecialty consultation 21. Delay: Physical Therapy/Rehabilitation 22. Delay: Trauma team arrival 23. Delay: Trauma team notification 24. Delay: Treatment 25. Delay: Discharge 26. DVT/PE Prophylaxis: Inappropriate 27. Equipment: Failure 28. Equipment: Unavailable 6 29. Fall 30. Hemorrhage Control 31. Hypothermia: Inappropriate assessment 32. Hypothermia: Inappropriate warming measures 33. Immobilization: Inappropriate or inadequate 34. Inappropriate transfer to Floor/ICU 35. Inappropriate use of CT 36. Infection: Central Line 37. Infection: Nosocomial (Other) 38. Missed Diagnosis 39. Monitoring: Inappropriate 40. Nursing: Delay in notification of patient event 41. Nursing: Documentation issue 42. Nursing: Medication issue 43. Nursing: Transfusion Issue – Removed. 44. Nutrition issues 45. OR Delay: Other 46. OR Delay: Anesthesia Related 47. OR Delay: Availability 48. OR Delay: Resuscitation 49. OR Delay: Transportation – Removed 50. Organ Procurement Issues
POPIMS_Manual_2014_Final.docx