Table 1

Types of patient safety events

Event typeExample/Source
Voluntary reported patient safety events
 Medication/Fluid eventAdverse reaction, missed dose
 Skin/Tissue injuryPressure ulcer
 Diagnosis/TreatmentDelay in diagnosis
 Radiologyabnormal results not reported
 Surgery/ProcedureCount discrepancy
 Lab/SpecimenDocumentation wrong patientWrong patient identified
 Feedback from patientsGrievance
 FallsFrom bed
 Communication/Coordination/Handoff issues:Inappropriate discharge
 Infection eventsIsolation inadequate
 Patient ID/Documentation/ConsentConsent issue
 Intravenous access issueDisconnected, infiltration
 Code blueCardiac or pulmonary arrest
 Code purplePsychiatric emergency
 Respect and dignityEmotional harm to patient
 Professional conductDiscrimination
 Blood productContraindication to administration
 Maternal/ChildbirthMaternal death
 NutritionPatient given food when NPO
 RestraintsInjury-restraint related
Automated patient safety events
Clostridium difficile infectionMicrobiology
 Bloodstream infectionMicrobiology
 Unrecognised bleedingLab
 PTT >100 while on heparinLab and pharmacy
 INR >6 while on warfarinLab and pharmacy
 Glucose <50 while on insulinLab and pharmacy
 Acute renal injuryLab
 Administration of vitamin KPharmacy
 Administration of naloxonePharmacy
  • *~10% of the orders of naloxone were dispensed but not administered.

  • INR, international normalised ratio; PTT, partial thromboplastin time.