Testing Issue Wrong Test Med Process Narcotic Discrepancy – – Performed Med Process Order Incorrect – Med Process Prescription/Refill – Line/Tube Med Timing Duration Incorrect – Disconnected Med Timing Frequency Wrong – Discontinued Incorrectly Med Timing Incorrect – Dislodgement Monitoring Error (Lab Value, Vital – Sign) Monitoring Failure To Maternal/Childbirth – Monitoring Other – Apgar Score < 5 at 5 Min Pain Management Inadequate Birth Trauma Patient Incorrect – DVT (Deep Vein Thrombosis) Quantity Incorrect Fetal Death in Labor Rate Incorrect Intrapartum Death Route Incorrect Maternal Death – Site Incorrect Maternal Infection – Storage Incorrect Maternal Other – Strength/Concentration Incorrect – Neonatal Death – Patient ID/Documentation/Consent Neonatal Other – Other Armband Absent – Pulmonary Embolism Armband Wrong DOB – RN Attended Birth Armband Name – Seizure Within First 24 Hrs of Birth Armband Patient – Shoulder Dystocia Consent None – Unanticipated Transfusion Consent Unsigned/Incomplete – Undiagnosed/Untreated Consent Wrong Procedure Listed – Hyperbilirubinemia Consent Wrong Side/Site Listed – Unexpected Transfer to ICU Date of Birth Incorrect – Unexpected Transfer to NICU Date of Birth Mssing – Uterine Rupture DNR - Wristband Documentation Incorrect Medication/Fluid – Documentation Missing – Administration Technique Incorrect Fax Event Document Faxed to Wrong – Contraindicated Drug-Disease – Number Contraindicated Drug-Drug – HIPAA Privacy Incident Contraindicated Drug-Food – Other Contraindicated Known Allergy – Scan Document Scanned to – Contraindicated – Wrong EMR Dose Incorrect Dosage Form – Task Event Task Entered on Wrong – Dose Incorrect Extra Dose – EMR Dose Incorrect Omitted – Task Event Task Sent to Wrong – Dose Incorrect Overdose – Provider/Office Dose Incorrect Underdose – Provision of Care Dose Incorrect Unknown Dose – Med Contaminated – Admission Issue Med Deteriorated – AMA Med Expired – Cardiopulmonary Arrest Outside of Med Incorrect – ICU Setting Med Unauthorized – Complication Following Spinal Med Process Dispensing – Manipulative Therapy Incorrect Delay/Failure to Monitor Alarm Med Process Disposal Inappropriate – Setting/Function Med Process Med Not Ordered – of Communication of Critical Med Process Medication List – Data Incorrect
Testing Issue – Wrong Test Performed Line/Tube Disconnected Discontinued Incorrectly Dislodgement Maternal/Childbirth Apgar Score < 5 at 5 Min Birth Trauma DVT (Deep Vein Thrombosis) Fetal Death in Labor Intrapartum Death Maternal – Death Maternal – Infection Maternal – Other Neonatal – Death Neonatal – Other Other Pulmonary Embolism RN Attended Birth Seizure Within First 24 Hrs of Birth Shoulder Dystocia Unanticipated Transfusion Undiagnosed/Untreated Hyperbilirubinemia Unexpected Transfer to ICU Unexpected Transfer to NICU Uterine Rupture Medication/Fluid Administration Technique Incorrect Contraindicated – Drug-Disease Contraindicated – Drug-Drug Contraindicated – Drug-Food Contraindicated – Known Allergy Contraindicated – Dose Incorrect – Dosage Form Dose Incorrect – Extra Dose Dose Incorrect – Omitted Dose Incorrect – Overdose Dose Incorrect – Underdose Dose Incorrect – Unknown Dose Med – Contaminated Med – Deteriorated Med – Expired Med – Incorrect Med – Unauthorized Med Process – Dispensing Incorrect Med Process – Disposal Inappropriate Med Process – Med Not Ordered Med Process – Medication List Incorrect Med Process – Narcotic Discrepancy Med Process – Order Incorrect Med Process – Prescription/Refill Med Timing – Duration Incorrect Med Timing – Frequency Wrong Med Timing – Incorrect Monitoring – Error (Lab Value, Vital Sign) Monitoring – Failure To Monitoring – Other Pain Management Inadequate Patient – Incorrect Quantity Incorrect Rate Incorrect Route Incorrect Site Incorrect Storage Incorrect Strength/Concentration – Incorrect Patient ID/Documentation/Consent Armband – Absent Armband – Wrong DOB Armband – Name Armband – Patient Consent – None Consent – Unsigned/Incomplete Consent – Wrong Procedure Listed Consent – Wrong Side/Site Listed Date of Birth – Incorrect Date of Birth – Mssing DNR - Wristband Documentation – Incorrect Documentation – Missing Fax Event – Document Faxed to Wrong Number HIPAA Privacy Incident Other Scan – Document Scanned to Wrong EMR Task Event – Task Entered on Wrong EMR Task Event – Task Sent to Wrong Provider/Office Provision of Care Admission Issue AMA Cardiopulmonary Arrest Outside of ICU Setting Complication Following Spinal Manipulative Therapy Delay/Failure to Monitor Alarm Setting/Function of Communication of Critical Data
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