Table 2

Events by category and type (N=210)

CategoryTypeNo. (no. with known harm)
Care transfer or dischargeInpatient bed availability—delay or failure31
Patient left ED before completion of visit11
Delay in transfer of care not related to bed availability7
Incomplete discharge2
Inadequate follow-up2
Laboratory testingResults—delay or failure to report20
Performance—delay or failure to obtain specimen4
Ordering—delay or failure to order3
Performance—lost or misplaced specimen2 (1)
Performance—haemolysed specimen2
Results—delay or failure to act on results2
Radiology testingPerformance—delay or failure to perform13
Results—delay or failure to report results5
Performance—wrong study performed3 (1)
Ordering—delay or failure to order1
Ordering—wrong study ordered1
Results—discrepancy in reading1
ED evaluationDelay or failure to evaluate10
Mis-triage (includes over- and undertriage)5
Inaccurate or incomplete triage evaluation4 (1)
Prolonged time in waiting room3
Inaccurate evaluation1 (1)
Other1
ED consultationConsultant evaluation—delay or failure18
Consultant communication—delay or failure2
Inadequate resident or fellow supervision1 (1)
MedicationsDispensing—delay or wrong time5
Medication not available in ED3
Ordering—delay or failure2
Administration—delay or failure2
Adverse drug event1 (1)
Medication not available from pharmacy1
Ordering—wrong dose1
Ordering—wrong time1
Dispensing—wrong route1
ProceduresIntravenous access—unanticipated difficulty obtaining access7 (7)
Other procedures—unanticipated difficulty2
Intravenous access—intravenous malfunction1 (1)
Communication6
Documentation6
Patient factors (eg, intoxication, behavioural issues)5
Patient complaints4
Other testing1
Not enough information to classify5

  • ED, Emergency Department.