Appendix 1 Criteria used for defining adverse clinical occurrences
Laboratory based triggers
INR >5
K<2.8, K>6.0
Na <120, Na >150
Cr >25% change
AST>500 or 3-fold increase
ALT>500 or 3-fold increase
tBili>30 or 3-fold increase
Alp >250
CK>500
TNT>0.10
Glucoscan<3.0
Glucoscan>18 *2
WBC<3.0
WBC>18
Hb decrease > 20%
Plt decrease by > 50%
Calcium<1.5
Calcium>3.0
Phospate<0.4
Mg <0.4
Mg > 5.0
pH<7.25
pH>7.5
HIT assay positive
Positive blood culture
Positive c.difficile toxin assay
Pharmacy based triggers
Order for flumazenil
Order for nalaxone
Order for Vitamin K
Order for Protamine
Order for FFP
Patient based triggers
Respiratory distress/Dyspnea
Chest pain
O2 sat <90%
Systolic BP <100
HR>110
Temp>39C, Temp<35C
Rash
Nausea/Vomitting
Unexpected death
Diagnosis based triggers
New DVT/PE
New Pressure Ulcer
Fall resulting in injury
Altered Level of consciousness
Family/Patient dissatisfied with care
Ventilator associated pneumonia
CV Line infection
CV Line complication – pneumothorax
CV Line complication - arterial injury
CV Line complication - difficult insertion (>3 attempts)
CV Line complication – other
Arterial Line complication
Inadequate sedation
Excessive sedation
Failure to wean from ventilation
Ogilvies syndrome
Pneumothorax
Return to OR
New gastric/duodenal ulcer
ETT complications: extubation
ETT complications: hypotension
ETT complications: trauma
ETT complications: aspiration
ETT complications: prolonged hypoxemia
System based triggers
Stat ECG
New Isolation Precautions
Use of physical restraints
Admission due to rapid response team call
Admission due to cardiac arrest
Unable to obtain MD in a timely manner
Unable to obtain consultant in a timely manner
Medication administration error
Equipment unavailable in emergency situation
Medical equipment problem
Nightime/Weekend admission
IV pump error
Delay in therapy
OR cancellation
Diagnostic Error
Other
Appendix 2 Adverse Events
ID
1
Preventable
YES
Class
Therapeutic error
YES
Therapeutic error
YES
Diagnostic error
YES
YES
Procedural
complication
ADE
YES
System error
NO
Surgical complication
8
9
Description
Bleeding in a post operative patient put on anti-coagulants for
questionable indication.
Pulmonary edema causing respiratory failure as a result of a
delay in instituting hemodialysis.
Several errors in diagnosis and management leading to the
death of a critically ill patient.
Dislocated jaw secondary to intubation. There was a several
week delay in making the diagnosis.
Pt develops abdominal hematoma secondary to IV heparin.
There was a delay in diagnosis.
Patient developes VAP following delayed surgery. Patient was
ventilated unnecessarily while awaiting operation.
Inadvertent damage to bowel during the emergency repair of a
ruptured AAA.
Intracerebral bleed complicating thrombolytic treatment.
Post operative MI in AAA repair patient
NO
NO
10
11
12
13
14
15
16
Surgical infection
Post-operative bleeding
Surgical infection
VAP
VAP
VAP
CVC-associated infection
NO
NO
NO
YES
YES
YES
NO
17
18
19
Vancomycin associated acute renal failure
VAP
CVC-associated infection
NO
YES
YES
20
21
22
23
24
25
26
Post operative bleeding and ischemic bowel.
VAP
VAP
VAP
VAP
Surgical infection
Difficulty with line insertion resulting in neck hematoma.
NO
YES
YES
YES
YES
NO
YES
27
28
YES
YES
29
Patient fall
Hypoglycemia in patient on insulin drip. Protocol for monitoring
glucose was not followed.
Arterial injury during CVC insertion
ADE
Procedural
complication
Surgical complication
Surgical complication
Surgical complication
Nosocomial infection
Nosocomial infection
Nosocomial infection
Procedural
complication
ADE
Nosocomial infection
Procedural
complication
Surgical complication
Nosocomial infection
Nosocomial infection
Nosocomial infection
Nosocomial infection
Surgical complication
Procedural
complication
Therapeutic error
ADE
30
Arterial injury during CVC insertion
YES
31
32
YES
YES
33
Bleeding on heparin. Heparin was not indicated.
Delayed response from consultant leading to prolonged patient
distress.
CVC associated bleeding
34
Pressure ulcers
NO
35
Pneumothorax following chest tube insertion.
NO
2
3
4
5
6
7
YES
NO
Procedural
complication
Procedural
complication
Therapeutic error
Therapeutic error
Procedural
complication
Procedural
complication
Procedural
complication
36
Pneumothorax following thoracentesis.
NO
37
38
Heparin induced thrombocytopenia
Hypotension following intubation
NO
NO
39
40
41
42
43
44
Clostridium difficile infection
Bleeding secondary to concomitant CVC and anticoagulants
Medication rash
Dilantin induced leucopenia
Central nervous system MRSA infection
Pneumothorax following chest tube insertion.
NO
NO
NO
NO
NO
NO
45
Failed extubation
NO
46
47
48
Excessive sedation
Medication rash
Delirium
NO
NO
NO
49
50
51
52
Heparin induced thrombocytopenia
Transfusion reaction
Medication rash
CVC associated DVT
NO
NO
NO
NO
53
Pressure ulcer
NO
54
55
56
Medication rash
Bacteremia
CVC associated bleeding
NO
NO
NO
Procedural
complication
ADE
Procedural
complication
Nosocomial infection
ADE
ADE
ADE
Nosocomial infection
Procedural
complication
Procedural
complication
ADE
ADE
Procedural
complication
ADE
ADE
ADE
Procedural
complication
Procedural
complication
ADE
Nosocomial infection
Procedural
complication
VAP=ventilator associated pneumonia; AAA=abdominal aortic aneurysm;
CVC=central venous catheter; MRSA=methicillin resistant staphylococcus aureus;
DVT = deep venous thrombosis