TableĀ 1

Frequency of patient safety issue by category

CategoryExampleN (%)
MedicationPatient presenting with seizures received a medication lowering the seizure threshold22 (20)
ProcedurePatient pulled suture out1 (1)
Wrong patientWrong patient's UA reported on rounds1 (1)
Electronic medical recordDifficult to put in orders for a stress echo2 (2)
CommunicationOrders put in by other service without knowledge of primary team12 (11)
LabUA ordered but not reported2 (2)
Delay in diagnosisWrong team called for a procedure (also communication)9 (8)
Treatment errorPatient supposed to be on antibiotics but was not11 (10)
DischargeDischarge delayed because of holiday weekend4 (4)
RadiologyInadequate amount of contrast given for CT7 (7)
EnvironmentWrong date on the white board in patient room19 (18)
OtherNo hand hygiene17 (16)
  • UA, urinalysis; VA, Veterans Affairs.