Patient Safety & Quality
Patient Safety & Quality
Embedded Files
Communication Opportunities
Accessibility of surrogate decision maker
Closing the loop on specialty recommendations
Competent patient not involved in conversation
Escalation of concerns through nursing hierarchy
Escalation of concerns through physician hierarchy
Inconsistent messaging to patient/family
Inappropriate patient/family contact after death
Interpreter could have been used
Nursing concerns not "heard" by physician teams
Patient/Family concerns not "heard" by care team
Physician not make aware of clinical condition
Release of protected health information
Unable to connect/contact physician care team
Other communication opportunities
Documentation Opportunities
Conflicting documentation
Resuscitation status differs from prior documentation
Missing or incomplete charting
Vital sign documentation
Physician documentation opportunity
Attending visit documentation missing
Copy/Paste of clinical notes
Death note/summary missing
Clinical scenario not accurately reflected
Informed consent missing or incomplete
Missing documentation of differential diagnosis
Missing documentation of thought process
Missing physical exam documentation
Missing procedure note
Other MD documentation opportunity
Other documentation opportunity
Documentation coding opportunities
Other RN documentation opportunity
Nursing/allied health documentation opportunity
Diagnostic Opportunities
Appropriate diagnostic test not ordered
Clinical decision making/strategy missing
Definitive diagnosis not pursued/reached
Diagnosis not consistent with labs/tests/documentation
Differential diagnosis/consideration missing
Follow-up on laboratory/test findings not apparent
Pursuit of autopsy not apparent
Specialty input/evaluation delayed/ not obtained
Workup/evaluation of sign or symptom missing
Other diagnostic opportunity
Delayed or missed Diagnosis
Cardiac
Electrolyte or acid-base
Endocrine
Exsanguination
Gastroenterology
Hematology / Oncology
Infectious disease
Neurologic
Orthopedic
Pulmonary (non-vascular)
Renal
Sepsis
Substance or medication withdrawal or reaction
Vascular (non-cerebrovascular)
Other delayed or missed diagnosis
Deteriorating patient opportunities
Intensity of treatment not sufficient for illness
Severity of illness not recognized
RRT/MET not called according to policy
RRT/MET was called but...
Care team's concerns not shared by RRT/MET
ICU was full
RRT/MET recommendations not appropriate
RRT/MET monitoring recommendations not executed
Other RRT/MET opportunity
RRT could have assisted (but not available at hospital)
Other
Treatment Opportunities
Appropriate specialty input missing
Appropriate treatment not ordered
Clinical pathway not followed
Delay in care
Attending evaluation/treatment
Drug or other therapy
Laboratory or test
Nutrition
Procedure or surgery
Specialty consult or input
Transfer to level of care needed
Other treatment delay
Documented plans not implemented
Existing protocol/pathway/orderset not adequate
Feet dragging - next steps unlikely to improve outcome
Intensity of care not sufficient for degree of illness
Needed interventions/tests not available
No standard of care exists
Orders not completed/carried out
Over-utilization of testing/treatment
POLST or patient wishes not honored
Right treatment performed in the wrong place
Other treament opportunities
Transition of Care Opportunities
Bed or staffing in appropriate level
Incomplete information from prior setting
Nursing hand-off between shifts
Physician team handoffs
Social work/discharge planning needed
Other transition of care opportunities
Triage Opportunities (from where to where)
Any home or outpatient area
Outside facility (hospital or ED)
the Emergency department
a General care unit
Stepdown/Intermediate Care Unit
an ICU/CCU
a PACU or post procedural area
an OR or procedural area
Other area
End of Life Opportunities
Ethics team could have been engaged
Excessive and futile care
Family/POA reversed patients goals of care
Family support/dynamics
Family's/patient's expectation management
Goals of care not evident
Palliative care team could have assisted
Symptom management
Delirium/agitation
Emotional (anxiety/depression, etc)
Excessive pain
Insomnia (impaired sleep/wake cycle)
Secretion control
Spiritual support
Tachypnea/dyspnea
Other end of life opportunity
Technology Opportunities
Battery/power failure
Device/pump malfunction
EHR Outage
EHR rules/process failure
Other technology failure
Hospital Acquired Infections
Hospital acquired pneumonia
Surgical/procedural site infections
Clostridium difficile
MRSA or VRE / CAUTI / CLABSI / VAP / Other
Medication/Blood Opportunities
Class of medication opportunity
Medication ordered is contraindicated
Medication dosing not appropriate
Medication cancelled/held, but given
Medication ordered, but not given
Medication reconciliation opportunity
Wrong medication delivered
Transfusion opportunity
Protocol not followed
Transfusion indication
Transfusion reaction
Over transfusion
Other medication/blood events
Prophylaxis Opportunities
Aspiration prophylaxis
Decubitus ulcer prophylaxis
GI prophylaxis
Thrombo-embolic prophylaxis
Other
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