Summary of central event analysis
| Month | Topic | No of events | Highest frequency event (n) | No of miscoded variables | “E-Reporter” feedback messages | ||
|---|---|---|---|---|---|---|---|
| Event classification | Level of impact | Location | |||||
| DVT/PE = deep vein thrombosis/pulmonary embolism. | |||||||
| *315 of the 421 are sponge/needle/instrument counts. | |||||||
| June 2002 | Respiratory | 22 | Extubation (10) | 6 | 1 | 1 | • Correct coding of extubations • Use of drop down menus to reduce use of “other” • Evaluation of disposable tracheostomy tubes |
| July 2002 | Skin integrity | 50 | Burns (14) | 16 | 19 | 0 | • Correct coding of level of impact for skin compromise |
| • Use of drop down menu detail for pressure ulcer staging | |||||||
| • Correct technique for positioning and taping intravenous and nasal gastric tubes | |||||||
| Sept 2002 | Laboratory issues | 26 | Delays (9) | 7 | 9 | 5 | • Correct coding of errors of omission • Distinction between event location and location impacted |
| • Monthly laboratory report of defective specimens sent to patient care units | |||||||
| Oct 2002 | DVT/PE | 15 | DVT (12) | 0 | 5 | 0 | • Correct coding of embolic event to activate state reportable alert feature |
| • DVT/PE research project underway addressing prevention/detection/treatment/reporting | |||||||
| Dec 2002 | Operative/invasive procedure | 106* | Counts/incorrect technique (24) | 26 | 11 | 0 | • Correct coding to distinguish faulty equipment from operator usage. • Product evaluation and education on use of electrosurgical units. |