Frequency of patient safety issue by category
| Category | Example | N (%) |
|---|---|---|
| Medication | Patient presenting with seizures received a medication lowering the seizure threshold | 22 (20) |
| Procedure | Patient pulled suture out | 1 (1) |
| Wrong patient | Wrong patient's UA reported on rounds | 1 (1) |
| Electronic medical record | Difficult to put in orders for a stress echo | 2 (2) |
| Communication | Orders put in by other service without knowledge of primary team | 12 (11) |
| Lab | UA ordered but not reported | 2 (2) |
| Delay in diagnosis | Wrong team called for a procedure (also communication) | 9 (8) |
| Treatment error | Patient supposed to be on antibiotics but was not | 11 (10) |
| Discharge | Discharge delayed because of holiday weekend | 4 (4) |
| Radiology | Inadequate amount of contrast given for CT | 7 (7) |
| Environment | Wrong date on the white board in patient room | 19 (18) |
| Other | No hand hygiene | 17 (16) |
UA, urinalysis; VA, Veterans Affairs.