Department    Frequency     Frequency      Event
                             Severity

ICU               3

Pharmacy          1

General Surgery  18             4          Med delay (AB x2 day) 24 hour chart check
                                4          Patient not seen within 24 hours of 
                                           admission
                                4          Inappropriate med dosage,time, etc. MAR 
                                           Problem
                                3          Orders for Metabolic Support (TPN) not 
                                           followed
                                3          Pt. off floor without orders
                                3          Pt. NPO was provided water and water 
                                           pitcher.
                                3          Order (clamp NG tube) not carried out
                                3          Medication error; med repeated at 
                                           inappropriate time
                                3          Patient complaint; poor quality
                                3          Wrong medication administered           
                                           (antibiotic)
										   
Orthopedics       2             4          Delay in providing antibiotics (2 days)         
                                           See #60
                                3          Pt. not admitted from STO status
								
Medical/Onc      13             4          Procedure not completed: physician no 
                                           show
                                4          Medication delay (AB) x3 days: MAR               
                                           Problem/faxing
                                4          Pt. admitted diarrhea/dulcolax on 
                                           standing order
                                4          Delay in Medication admin/MAR Problem/24 
                                           hr chart check
                                4          IV med inappropriate time/Blood hung with 
                                           D51/2NS 10KCL
                                3          Documentation error; wrong date for wd 
                                           care order
                                3          Medication delay; Med available in pyxis
                                3          Patient allowed up to BSC with bedrest 
                                           only orders
                                3          Delay in Medication admin/MAR Problem/24 
                                           hr chart check
                                3          Orders not noted IV med not hung
								
BC/Postpartum     1

Pediatrics        3             4          Sentinel Event- ASO
                                3          STO order not changed to inpt/2 Inpt days            
                                           missed.

SNU               7             4          Delay in response to pt condition/Delay             
                                           notification of Dr.
                                4          Wound Care not followed/MAR problem
                                4          4 doses of antibiotics missed/MAR problem
                                3          Delayed transfer to SNU

Day Surg          3

Endoscopy         2             3          Wound care orders delayed
                                3          Colostomy education ordered, delayed 3 
                                           days

OR                1             4          Op Report with wrong pre-op DX/Procedure

Cardiology        3             4          Transport with malfunct. equip./Drips 
                                           rates reversed
                                3          Anticoag Med not given; Inappropriate 
                                           phys. Document.
                                3          Delay in stat lab results

Metabolic Supp    1             4          Metabolic services treatment delayed

PAR               1             4          Patient allergies MS; MS given in PAR

ER                1             3          Pt. not seen by 24 hr from admission

Resp Care         1             4          Delay in obtaining sputum culture (2 
                                           days) See # 61