Examples of Reported Events From Phases 1 and 2

Errors of diagnosis
 Radiograph to assess central venous catheter placement not done until the next day
 Abnormal newborn screen result not noted, found 10 days later
 Echocardiogram performed on wrong patient
 Low blood glucose value not discovered for almost 3 hours
 Serum potassium level reported to be 2.8 mEq/L when actually 6.8 mEq/L
 Culture of cerebrospinal fluid not ordered, necessitating repeat entry into shunt system
Errors of treatment
 Accidental dislodgement of central venous catheters, resulting in blood loss
 Catheter malposition leading to complications such as pericardial effusion and liver damage
 Tracheal perforation and pneumothorax as a result of excessive insertion depth of endotracheal suction catheter
 Preterm infant experienced hypoxia during transport as oxygen tank of ambulance was not turned on
 Ventilator malfunction leading to undesirably high or low pressures
 Burn to penis from hot Mogen clamp during circumcision
 Towel clip placed through infant’s finger during procedure
 Urethral rupture from inflation of balloon of urinary catheter
 Intravenous administration of milk and of oral medications
 Intratracheal administration of enteral feeds
 Intravenous lipid given through orogastric/nasogastric tube
 Hundred-fold overdose of insulin
 Administration of fosphenytoin instead of hepatitis B vaccine
 Subtherapeutic dose of penicillin for group B Streptococcal infection given for 3 days before discovery
 Infusion of total daily intravenous fluids over 1–2 hours
 Intravenous administration of lidocaine instead of saline flush
 “Stat” blood transfusion took 2.5 hours
 Antibiotic given 4 hours after ordering
 Delay of >1 hour in obtaining intravenous dextrose to treat hypoglycemia
 Medications given to the wrong patient
 Infant fed breast milk of wrong mother
Other errors
 Consent for a blood transfusion obtained from wrong infant’s parent
 Infant falls from weighing scale, incubator, and swing
 Failure of supply of compressed air throughout NICU
 Incubator drawn toward magnetic resonance imaging machine requiring 4 security guards to pull it away