Event type | % of much better outcomes | % Actions effecting “much improved” outcomes | |
Pre | Post | ||
Communication of abnormal results | 23% | 34% | 14% Standardisation of processes* |
9% Software/hardware | |||
7% Addition of new device | |||
Delay in treatment/surgery/diagnosis | 23% | 39% | 16% Standardisation of processes* |
13% CQI (Continuous quality improvement) | |||
Fall | 16% | 31% | 14% Standardisation of processes* |
8% Addition of new device | |||
7% Enhanced documentation/communication | |||
High alert ADEs | 19% | 35% | 19% Standardisation of processes* |
12% Software/hardware | |||
Hospital acquired infections | 22% | 45% | 16% Standardisation of processes* |
9% Enhanced documentation/communication | |||
8% Addition of new device | |||
Incorrect surgery | 25% | 43% | 17% Standardisation of processes* |
13% Enhanced documentation/communication | |||
8% Enhanced information display | |||
Inpatient parasuicide | 18% | 22% | 15% Standardisation of processes* |
10% Enhanced documentation/communication | |||
Laboratory | 24% | 38% | 15% Standardisation of processes* |
10% Enhanced information display | |||
7% Enhanced documentation/communication | |||
Medical device | 24% | 50% | 22% Standardisation of processes* |
6% Updating/adjusting manuals/contracts/personnel files | |||
Medication use process | 18% | 27% | 17% Standardisation of processes* |
13% Staffing/scheduling/assignments | |||
Misidentification | 23% | 42% | 19% Standardisation of processes* |
7% Software/hardware | |||
Missing patient | 21% | 39% | 17% Standardisation of processes* |
11% Enhanced documentation/communication | |||
Mixing/packaging ADEs | 33% | 46% | 19% Standardisation of processes* |
7% Software/hardware | |||
6% Addition of new device | |||
6% Visual warning | |||
Outpatient suicide | 10% | 26% | 15% Standardisation of processes* |
11% Enhanced documentation/communication | |||
Oxygen | 19% | 18% | 17% Standardisation of processes* |
15% Enhanced documentation/communication | |||
8% Enhanced information display | |||
Radiology | 15% | 34% | 16% Standardisation of processes* |
13% Enhanced documentation/communication | |||
12% Software/hardware | |||
Retained objects surgeries/procedure | 27% | 26% | 26% Standardisation of processes* |
Unexpected death | 19% | 33% | 17% Standardisation of process* |
9% Staffing/scheduling/assignments |
Expanded definitions of all the above action categories can be found at: http://www.patientsafety.gov/PACGlossary.pdf.
Not listed are Policy/Procedures and Staff Training though they are complementary actions for most event types. Rating of “much better” are made by the Patient Safety Managers at each facility'.
↵* Standardisation of processes (protocols, clinical guidelines, order sets).