Department      Frequency        Freq       Event
                               Severity

ICU                 4             4         Pt had neuro changes/No 
                                            documentation Dr. notified
                                  4         Procainamide gtt ordered/not started

Physical Ther.      5             4         PT Eval ordered not completed >10days
                                  4         PT Eval ordered not completed >10days
                                  4         PT Eval ordered on admit not completed 
                                            for 5 days
                                  4         PT Eval ordered not completed for 3 days
                                  3         No PT for 9 days after pt. refused/No                      
                                            order canceling

General Surgery     6             4         Order for Peritoneal Dialysis 
                                            exchange/Delay in treatment >6 hours
                                  4         Pt not seen by physician within 24 hours 
                                            of admission
                                  3         Echo delayed 1 day
                                  3         Pt. scheduled for Infusaport not 
                                            NPO/procedure delay/2 avoidable days
                                  3         Nurse ordered Hepatitis functio panel 
                                            instead of Hepatic function panel

Orthopedics         3             3         Orders to DC IV meds start on 
                                            PO/Continued to receive IV meds x24 
                                            hours

Medical/Onc         5             4         1 unit PRC given/No order to give/Order 
                                            T&S 4 units PRC
                                  4         Pt. not seen within 24 hours of 
                                            admission by physician
                                  3         Delay in procedure due to no prep given
                                  3         Dobutrex gtt ordered not hung for 24 
                                            hours

Gero Psych          1             3         Pt. given medications without proper ID 
                                            armband in place

SNU                 7             4         Pt. fall
                                  4         Pt. fall
                                  3         UA/Cult ordered to be followed by AB/AB 
                                            started with UA/Culture obtained
                                  3         Trsf to SNU IV heparin hanging/No orders                   
                                            for IV heparin
                                  3         Pt. without IV for >24 hours/difficulty 
                                            est PICC/No one available to insert

Rehab               1

Endoscopy           3             4         Colostomy teaching ordered/not completed 
                                            prior to discharge
                                  4         Colostomy teaching ordered/not completed 
                                            prior to discharge
                                  3         Ostomy consult ordered/Packet left for 
                                            pt/No followup teaching

Cardiology          1

P A R               1

Lab                 1