Table 3

 Examples from common incident type and preventability categories

Event typeExamples from categories representing at least 2% of all incidents
OperationsPreventability indeterminate: consent form or patient understanding differed slightly from procedure performed (numerous incidents).
Preventability indeterminate: patient returned to operating room due to early complications (few incidents).
Preventable: incorrect needle/sponge/instrument count (numerous incidents).
ProceduresPreventability indeterminate: patient removed his or her own invasive device (numerous incidents).
Preventability indeterminate: peripheral intravenous line infiltration or extravasation (numerous incidents).
Preventable: provider erroneously removed invasive device (few incidents).
MedicationsPreventable: dose omission (numerous incidents).
Preventable: wrong dose (few incidents).
Preventable: wrong patient (few incidents).
FallsPreventability indeterminate: unwitnessed fall or probable fall (eg, patient found on floor) (numerous incidents).
DiagnosticPreventable: problem initiating or performing a test (eg, drawing blood, performing imaging studies).
TherapeuticPreventable: pressure sore from current hospitalisation (numerous incidents).
Preventable: transfusion problems (eg, problems with orders, delays).
OtherNot preventable: patient became unstable/experienced cardiopulmonary arrest due to illness.
Preventability indeterminate: patient became unstable or experienced cardiopulmonary arrest for unclear reasons (numerous incidents).
Preventable: standard admission/discharge/transfer communication protocol not followed.