1 | Neurosurgery | 4 | ICU | Yes | No | No | Failure to follow brain death protocol (I) | Subarachnoid haemorrhage; ventricular fibrillation during brain death protocol |
2 | Cardiology | 3 | ICU | Yes | Yes | No | Delay in MET/RRS activation (III) | MI, cardiogenic shock; third degree heart block, asystole |
3 | Transplant surgery | 2 | ICU | Yes | Yes | No | Failure to reset AICD postoperatively (I) | Kidney transplant; postoperative day 2—ventricular tachycardia, AICD did not fire |
4 | Medicine | 0 | Procedure unit | Yes | Yes | Yes | Procedure complication (IV) | Duodenal polyps; arterial bleed; PEA |
5 | Medicine | 3 | Inpatient unit | Yes | No | No | Failure to keep patient in bed (I) | Cocaine misuse, CABG; alarm for bradycardia in bathroom |
6 | Cardiothoracic surgery | 4 | Inpatient unit | Yes | Yes | No | Surgical complication (IV) | CABG (×4); bleeding from arterial bypass |
7 | Medicine | 5 | Procedure unit | Yes | Yes | Yes | Procedure complication (IV) | Tachycardia-bradycardia syndrome; asystole during IVC filter insertion |
8 | Cardiothoracic surgery | 6 | Inpatient unit | Yes | Yes | Yes | Delayed tracheostomy (I) | Failed extubation (×2); emesis, aspiration, asystole |
9 | Cardiothoracic surgery | 0 | Inpatient unit | Yes | No | No | Delay in cardiopulmonary intervention (III) | Acute MI; transferred for CABG, PEA arrest 19 h later |
10 | Cardiothoracic surgery | 71 | Inpatient unit | Yes | Yes | No | Delay in MET/RRS activation; delay in ICU transfer (III) | Empyema; respiratory failure, delay in ICU transfer |
11 | Cardiology | 6 | Inpatient unit | Yes | No | No | Delay in MET/RRS activation; delay in ICU transfer (III) | CHF, cardiogenic shock, dobutamine drip started outside ICU; PEA |
12 | Neurosurgery | 7 | Inpatient unit | Yes | Yes | Yes | Mismatch of resources to illness severity (II) | Odontoid fracture, quadriparesis; aspiration, apnoea |
13 | Cardiothoracic surgery | 8 | Inpatient unit | Yes | Yes | Yes | Very sick inpatient had study in “outpatient” setting (I) | Obstructive sleep apnoea, lung cancer resection; ventricular tachycardia |
14 | Gastroenterology | 5 | Inpatient unit | No | No | No | Mismatch of resources to illness severity (II) | Aortic stenosis; chest pain, altered mental status, fever, arrest during prolonged evaluation by trainee |
15 | Geriatric medicine | 5 | Inpatient unit | No | Yes | No | Mismatch of resources to illness severity (II) | Aspiration pneumonia; hypoxaemia, emesis, aspiration, asystole. |
16 | Neurosurgery | 2 | Inpatient unit | No | No | No | Patient not on DVT/PE protocol (I) | Spinal stenosis; postoperative day 2—PEA, pulmonary emboli |
17 | Medicine | 1 | Inpatient unit | No | Yes | No | Inadequate monitoring; failure to continue BiPAP (I, II) | Myasthenia gravis, Ogilvie syndrome; BiPAP prescribed, removed to go to bathroom; asystole |
18 | Medicine | 4 | Inpatient unit | No | No | No | Mismatch of resources to illness severity (II) | Found pulseless and apnoeic in bed in the morning, 13 days after aortic valve replacement |
19 | Critical care medicine | 7 | Inpatient unit | No | Yes | No | No DVT/PE prophylaxis in the last 2–3 days (I) | Non-ketotic hyperosmolar coma; pulmonary emboli, PEA |