Blood/laboratory studies | | | |
Was a blood/laboratory test ordered and not sent? | 2.3 | 4 | 9 |
Was a blood/laboratory test drawn or sent on the wrong patient? | 0.6 | 1 | 9 |
Did a blood/laboratory test need to be repeated due to a procedural problem? | 4.5 | 7 | 8 |
Was a blood/laboratory specimen sent unlabeled or mislabeled with the wrong patient’s name? | 0.6 | 1 | 8 |
| | | |
Radiology studies | | | |
Was a radiological procedure ordered and not done? | 1.5 | 2 | 7 |
Did an x ray or other procedure need to be repeated due to a procedural problem? | 0.7 | 1 | 7 |
Was a requisition for a radiological procedure mislabeled? | ND | ⩾1 | 4 |
| | | |
Delays in patient service | | | |
Was there a delay in informing parents of a “significant” clinical event or significant change in clinical status? | 1.7 | 3 | 9 |
In the past 2 days, was a consultation ordered and not done? | 1.3 | 2 | 8 |
Did a delay in reporting a laboratory test or radiology result affect clinical management? | 0 | 0 | 6 |
Did a delay in responding to an alarm result in an adverse outcome? | 0 | 0 | 5 |
| | | |
Information transfer | | | |
Was important information that would affect the clinical management of a patient not transferred verbally or in writing? | 2.1 | 4 | 10 |
Were x rays/tests to be done on your shift not reported? | 0 | 0 | 7 |
| | | |
Patient care equipment/medical devices | | | |
Was a patient accidentally extubated? | 1.9 | 3 | 8 |
Did a ventilator malfunction? | 0 | 0 | 10 |
Was a chest tube accidentally dislodged? | 0 | 0 | 9 |
Did an alarm failure or malfunction cause a delay in treatment? | 0 | 0 | 5 |
Was there an IV infiltrate that caused injury? | 4.1 | 4 | 5 |
Did a CVC migrate or come out? | 0.7 | 1 | 7 |
| | | |
Patient transport | | | |
Did an adverse event occur while the patient was away from the NICU? | 0 | 0 | 5 |
| | | |
Pain | | | |
Were pain control measures during invasive procedures not used according to unit policy? | 1.0 | 1 | 5 |
Pain not assessed before invasive procedures | 0 | 0 | 4 |
| | | |
Errors detected | | ⩾35 | |