Table 4

Per cent of facilities reporting “much improvement” in their action close-out reports, by event type pre-Cornerstone to post-Cornerstone and actions associated with such improvement

Event type	% of much better outcomes		% Actions effecting “much improved” outcomes
Event type	Pre	Post	% Actions effecting “much improved” outcomes
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^*
Delay in treatment/surgery/diagnosis	23%	39%	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^*
High alert ADEs	19%	35%	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^*
Inpatient parasuicide	18%	22%	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^*
Medical device	24%	50%	6% Updating/adjusting manuals/contracts/personnel files
Medication use process	18%	27%	17% Standardisation of processes^*
Medication use process	18%	27%	13% Staffing/scheduling/assignments
Misidentification	23%	42%	19% Standardisation of processes^*
Misidentification	23%	42%	7% Software/hardware
Missing patient	21%	39%	17% Standardisation of processes^*
Missing patient	21%	39%	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^*
Outpatient suicide	10%	26%	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^*
Unexpected death	19%	33%	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).