Table 1

List of triggers and process identified

TriggerProcess identified
PTT=prothrombin time; INR=international normalized ratio; WBC=white blood cells.
T1: DiphenhydramineHypersensitivity reaction or drug effect
T2: Vitamin KOver-anticoagulation with warfarin
T3: FlumazenilOversedation with benzodiazepine
T4: DroperidolNausea/emesis related to drug use
T5: NaloxoneOversedation with narcotic
T6: AntidiarrhealsAdverse drug event
T7: Sodium polystyreneHyperkalemia related to renal impairment or drug effect
T8: PTT >100 secondsOver-anticoagulation with heparin
T9: INR >6Over-anticoagulation with warfarin
T10: WBC <3000 × 106/μlNeutropenia related to drug or disease
T11: Serum glucose <50 mg/dlHypoglycemia related to insulin use
T12: Rising serum creatinineRenal insufficiency related to drug use
T13: Clostridium difficile positive stoolExposure to antibiotics
T14: Digoxin level >2 ng/mlToxic digoxin level
T15: Lidocaine level >5 ng/mlToxic lidocaine level
T16: Gentamicin or tobramycin levels peak >10 μg/ml, trough >2 μg/mlToxic levels of antibiotics
T17: Amikacin levels peak >30 μg/ml, trough >10 μg/mlToxic levels of antibiotics
T18: Vancomycin level >26 μg/mlToxic levels of antibiotics
T19: Theophylline level >20 μg/mlToxic levels of drug
T20: Oversedation, lethargy, fallsRelated to overuse of medication
T21: RashDrug related/adverse drug event
T22: Abrupt medication stopAdverse drug event
T23: Transfer to higher level of careAdverse event
T24: Customized to individual institutionAdverse event