Table 3

 Summary of central event analysis

MonthTopicNo of eventsHighest frequency event (n)No of miscoded variables“E-Reporter” feedback messages
Event classificationLevel of impactLocation
DVT/PE = deep vein thrombosis/pulmonary embolism.
*315 of the 421 are sponge/needle/instrument counts.
June 2002Respiratory22Extubation (10)611• Correct coding of extubations • Use of drop down menus to reduce use of “other” • Evaluation of disposable tracheostomy tubes
July 2002Skin integrity50Burns (14)16190• 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 2002Laboratory issues26Delays (9)795• 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 2002DVT/PE15DVT (12)050• Correct coding of embolic event to activate state reportable alert feature
• DVT/PE research project underway addressing prevention/detection/treatment/reporting
Dec 2002Operative/invasive procedure106*Counts/incorrect technique (24)26110• Correct coding to distinguish faulty equipment from operator usage. • Product evaluation and education on use of electrosurgical units.