• Implemented throughout all clinical care areas |
• Levels 1 and 2 user types |
• 4 major event classifications: falls, medication, adverse clinical events, and administrative |
• 4 major events further classified into 71 subtypes and 301 secondary subtypes |
• Demographic/background information for each event |
• 18 questions with drop down menus |
• Open ended narrative to document incident details |
• Level of impact taxonomy (0–10): |
(0) Unknown: level of impact unknown at time of event report. |
(1) Safety environment: there are unsafe practices, conditions or circumstances that could cause an adverse event. |
(2) Near miss: event could cause adverse event but did not involve patient. |
(3) No harm—no increased monitoring: event involved patient but there was no harm. |
(4) No harm—increased monitoring: event involved patient, there was no harm, but there was increased monitoring. |
(5) Temporary harm—no treatment: temporary effect on patient. Intervention not instituted. |
(6) Temporary harm—minor treatment: temporary or reversible effect on patient. Intervention instituted. |
(7) Temporary harm—major treatment: temporary or reversible effect on patient requiring higher level of care such as initial or prolonged hospitalization. |
(8) Permanent harm: event occurred that may have contributed to permanent harm. |
(9) Near death event: for example, anaphylaxis or cardiac arrest. |
(10) Death: event may have contributed to patient death. |
• Contributing factors: human, system, patient, equipment, environmental |
• Recommendations for improvement |