TABLE 3.

Individual Incident Summaries

Incident ClassificationMethod of DetectionError TypeSeverity
Preventable AEs
    CIPs
        Tension pneumothorax in a patient after bag-mask ventilation and right main-stem intubation after an unplanned extubationChart reviewProceduralLife-threatening
        Urinary tract infection in a patient with a Foley catheterChart reviewPreventionSevere
        Temporary pulselessness in a lower extremity after an attempted femoral venous catheter placementChart reviewProceduralSevere
        Unplanned extubation during a portable chest radiograph requiring reintubationChart reviewPreventionSevere
        Unplanned extubation during a portable chest radiograph requiring reintubationChart reviewPreventionSevere
        Central venous catheter infectionChart reviewProceduralSevere
        Hypotension discovered in a patient with a negative fluid balance over prior 24 h that resolved with intravenous fluid bolusChart reviewPreventionSevere
        Weight loss in a patient with poor oral intake and delayed enteral nutritional support after improvement in respiratory statusChart reviewPreventionSignificant
    Non-CIPs
        Apnea and poor perfusion during a sepsis evaluation in a markedly dehydrated patient with delayed intravenous rehydration that resolved with intravenous fluid bolusesStaff reportPreventionSevere
        Hospital-acquired viral gastroenteritis that prolonged hospitalizationStaff reportPreventionSevere
        Unnecessary phlebotomy resulting from a lab error–false thrombocytopeniaChart reviewDiagnosticSignificant
        Unnecessary phlebotomy resulting from a lab error–false hypokalemiaChart reviewDiagnosticSignificant
        Sepsis evaluation, renal ultrasound, and voiding cystourethrogram performed in a patient with a false-positive urine cultureChart reviewDiagnosticSignificant
Intercepted NMs
    CIPs
        Delayed detection of a right main-stem intubation without apparent consequenceChart reviewProceduralSevere
        Intercepted overdose of a pancreatic enzyme (used to treat an occluded gastrostomy tube) without apparent consequenceStaff reportMedicationSevere
Non-intercepted NMs
    CIPs
        Prolonged hypoventilation in an intubated patient without apparent consequenceChart reviewPreventionSevere
        Tenfold paralytic overdose given to an intubated patient without apparent consequenceChart reviewMedicationSevere
        Delay in radiographic diagnosis of a pneumothorax without apparent consequenceChart reviewDiagnosticSevere
    Non-CIPs
        Delay in diagnosis of anemia in a patient with abnormal complete blood counts without apparent consequenceChart reviewDiagnosticSignificant
Errors with little/no potential for injury
    Non-CIPs
        Contaminated blood culture suspected to be a contaminant without additional interventionChart reviewProceduralNo injury
        Amoxicillin order (for otitis media) written for the wrong patient but not administeredStaff reportMedicationNo injury
Nonpreventable AEs
    CIPs
        Bacterial pneumonia diagnosed by a new infiltrate on chest radiograph 24 h after the patient was intubated during transport to the hospitalChart reviewSevere
    Non-CIPs
        Rash after antibiotic given to a patient with no known drug allergiesChart reviewSignificant
        Intravenous infiltrateChart reviewSignificant
        Fall from crib while parents were watching patientStaff reportSignificant
        Contact dermatitis from hospital bedding requiring medicationStaff reportSignificant