Scale of Severity of the Event

Incidents

A

Circumstances or events that have the capacity to cause error or damage (Risk Situation).

• Tile on the floor is loose/broken. Water on the floor. Threshold to bathroom broken and patient circulating in area.

• Inappropriate storage of medications (two medications with very similar packaging stored next to one another, poor lighting, too many distractions, etc).

• Staff person notes on-off switch is defective on infusion pump during inventory.

B

An error occurred but did not reach anyone (near miss).

• Lose tile is not fixed, client walks over lose/broken tile and trips but does not fall.

• Pharmcist identifies unidose system packing wrong dose of medication, correction is made. Client’s unidose arrives on the unit, nurse in verifying the medications to administer notices the wrong dose prior to administration.

• Prior to attaching infusion pump, nurse verifies flow rate and finds it defective. Nurse verifies pump with IV fluid intake volume found flow rate defective prior to administering medications, changes pump.

C

An error (including errors of omission) occurred that reached the person but did not cause consequences to the person, requiring no additional monitoring nor interventions.

• Client trips and falls, immediately gets up and continues walking, no injuries, no complaints of pain or injury. States he is fine, no need for monitoring.

• Wrong dose of medication given to client with no potential for consequences and no need for monitoring. e.g. dose given will not affect patient.

• Infusion pump running for 8 hours: fluid input volume does not match pump setting. Flow rating programming found to be defective; no consequences to client.

Accidents

D

An error occurred that reached the person where consequences were feared or anticipated, required monitoring to confirm that it resulted in no consequences and/or required intervention to preclude consequences to the person affected.

• Client falls, nurse checks for injuries and monitors gait. No injury found. Client has no complaints of pain or injury.

• Wrong dose of medication given to client that had no consequence but required further monitoring.

• Infusion pump running for 8 hours: fluid input volume does not match pump setting. Flow rating programming found to be defective, consequences to client noted: fluid overlaod requires monitoring.

E1

An accident occurred that may have contributed to or resulted in temporary consequences to the person affected requiring non specialized first aid or interventions to control/minimize the consequences.

• Client falls, complians of pain, has superficial scrapes requiring cleansing and dressing.

• Client received an overdose of warfarin resulting in an increased INR which required monitoring.

• Infusion pump running for 8 hours: fluid input volume does not match pump setting. Flow rate programming found to be defective, consequences to client noted: fluid overload requires monitoring and diuretics.

E2

An accident occurred that may have contributed to or resulted in temporary consequences to the person affected requiring intervention; supplementary specialized care or treatment without the need for prolonged hospitalization.

• Client falls, complains of pain, and requires an X-ray, no fracture noted.

• Client received an overdose of narcotics resulting in increased sedation (ie. 4) and requiring narcan to reduce/reverse effects.

• Infusion pump functioning for 8 hours: fluid input volume does not match pump setting. Flow rate programming found to be defective, consequences to client noted: Fluid overloadrequires monitoring and diuretics as well as cardiac monitoring

F

An accident occurred that may have contributed or resulted in temporary consequences to the person affected and required supplementary specialized care or treatment with an initial or prolonged hospitlization.

• Client falls, complains of pain, requires an X-ray, fracture noted, reduced (cast applied) with no permanent consequences.

• A delay in the initiation in antibiotic treatment resulting in the worsening pneumonia and septicemia resulting in prolonged hospitalization.

• Pump running for 8 hours fluid input volume does not match pump setting. Flow rate programming found to be defective, consequences to client noted: Fluid overload (requires monitoring and diuretics,) cardiac monitoring and an arrythmia requiring prolonged hospitalization.

G

An accident occurred that may have contributed or resulted in permanent consequences to the person affected.

• Client falls, consequent hip fracture, leads to permanent disability.

• Client received an over-dose of vancomyocin resulting in permanent hearing loss.

• Infusion pump malfunction goes undetected, leads to fluid overload, electrolyte imbalance, resulting in an arrythmia and myocardial infarct.

H

An accident occurred that required intervention necessary to sustain life.

• Client falls and suffers a subdural hematoma, requiring intubation and transfer to critical care unit.

• Overdose of narcotics resulting in respiratory depression necessitating use of naloxone, CPR and transfer to critical care.

• Equipment malfunction goes undetected, resulting in a cardiac arrest requiring CPR and admission to CCU.

I

An accident occurred that may have contributed to or resulted in the person’s death.

• Client sustains a very bad fall, is transferred to ICU where he subsequently dies.

• Overdose of narcotics (10x correct dose) resulting in respiratory depression and subsequent death.

• Undetected malfunction of critical equipment leading to cardiac or respiratory arrest resulting in death.