Table 1

 Pediatric Patient Safety Taxonomy

(I) Event type
    (1) Problematic decision
    (2) Problematic execution
    (3) Problematic communication
    (4) Technical/mechanical malfunction
    (5) Insufficient information
(II) Domains of medical care
    (1) Preventive medicine
        (A) Immunization
        (B) Preventive screening
    (2) Diagnostics
        (A) Medical history and physical examination
        (B) Tests
        (C) Reading, recording, and interpreting results
    (3) Treatment
        (A) Medications, blood products, fluids, diet
         (a) Ordering
         (b) Transcribing
         (c) Dispensing
         (d) Administration
        (B) Surgical and non-surgical procedures
         (a) Preparation
         (b) Procedure
        (C) Appointment scheduling, referral, and follow up communications
        (D) Other medical treatments
         (a) Psychiatric
         (b) Social services
         (c) Discharge planning
    (4) Patient monitoring
    (5) Patient communication
        (A) Preventive care
        (B) Diagnostic
        (C) Medication
        (D) Surgical care
        (E) Post-surgical care
        (F) Other medical treatment
    (6) Patient identification
    (7) Equipment
        (A) Equipment malfunction
        (B) Equipment availability
        (C) Use of equipment
    (8) Administrative
        (A) Medical record related
        (B) Other clinically significant administrative
(III) Contributing factors
(IIIA) Patient/child specific factors
    (1) Physical characteristics
        (A) Small size
        (B) Morphology
        (C) Varied size and morphology
    (2) Development
        (A) Physiological
         (a) Underdeveloped systems
         (b) Epidemiology
         (c) Growth
         (d) Child specific signs and symptoms
        (B) Cognitive, social-emotional
         (a) Ability to communicate
         (b) Ability to understand
         (c) Ability to control/regulate behavior
    (3) Minor legal status
        (A) Medical management
        (B) Decision making and consent
        (C) Confidentiality
        (D) Supervision
    (4) No contributing patient/child specific factor
    (5) Insufficient information to determine
(IIIB) Human factors
    (1) Cognitive
        (A) Knowledge
        (B) Confusion
        (C) Assumptions
        (D) Inattention
    (2) Physical
        (A) Fatigue
        (B) Physical pain
        (C) Physical performance of a task
    (3) Emotional
        (A) Fear
        (B) Dislike
        (C) Emotional stress
    (4) None
    (5) Unclassifiable/insufficient information
(IIIC) Latent conditions
    (1) Organizational systems
        (A) Systems for clinical communication
         (a) Across departments
         (b) Across professions
        (B) Systems of medication provision
         (a) Ordering
         (b) Preparing
         (c) Administration
        (C) Infection control systems
         (a) Hygiene
         (b) Prophylactic antibiotics
         (c) Infected clinicians/visitors
         (d) Evaluation
        (D) Systems of training
        (E) Systems for equipment acquisition and maintenance
    (2) Culture
    (3) Structure/framework of medicine
    (4) Physical environment design
    (5) Staffing
(IV) Outcomes
(IVA) The result of the problem
    (1) Near miss/good catch
    (2) Adverse drug event
    (3) Nosocomial infection
    (4) Cardiac arrest
    (5) Respiratory failure
    (6) Wrong treatment/procedure
    (7) Treatment of wrong patient
    (8) Wrong site surgery
    (9) Laceration
    (10) Excess bleeding
    (11) Loss of sensory input
    (12) Paralysis
    (13) Other neurological impairment
    (14) Organ system impairment
    (15) Fall
    (16) Burn
    (17) Fracture
    (18) Failed procedure
    (19) Breech of confidentiality
    (20) Adverse blood transfusion reaction
    (21) Patient missing
    (22) Unnecessary protective services involvement
    (23) Delayed growth/development
    (24) Disorientation
    (25) Loss of consciousness
    (26) Return to the ICU within 48 hours
    (27) Pain
    (28) Social disruption
    (29) None of the above but resulted in hospital
    (30) Admission or extended hospital stay
    (31) Death
    (32) Insufficient information to determine
(IVB) Level of harm
    (1) Near miss, error did not reach the patients, no harm
    (2) Reached the patient, no harm
    (3) Emotional harm
    (4) Minor temporary harm
    (5) Major temporary harm
    (6) Minor permanent harm
    (7) Major permanent harm
    (8) Death