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Safety Net

Perianesthesia Patient Safety Net with Related Event Types

For more information, please access this publication:
Krenzischek DA, Clifford TL, Windle PE, Mamaril ME. Patient safety: Perianesthesia nursing's essential role in safe practice. Journal of PeriAnesthesia Nursing, 22(6): 385-392, December 2007

I. Improve the accuracy of patient idenfification
        A. Identification Errors
        B. Final Verification Prior to Procedures

II. Improve the effectiveness of communication among caregivers
        C. Communication Errors

III. Improve the safety of using medications
        D. Medication Errors

IV. Eliminate Wrong-site, Wrong-patient, Wrong-procedure Surgery
        E. Wrong Site Surgery

V. Improve the Safety of using Infusion Pumps/Equipment
        F. Pumps/Equipment

VI. Improve the Effectiveness of Clinical Alarm Systems
        G. Monitor Alarm Error

VII. Reduce the Risk of Healthcare Associated Infections
        H. Healthcare Associated Infections

VIII. Reduce the Risk of Patient Harm Resulting from Falls
        I. Fall

IX. Reduce the Risk of Influenza and Pneumococcal Disease in Institutionalized Older Adults
        J. Influenza

X. Reduce the Risk of Surgical Fires
        K. Fires

XI. Implementation of Applicable National Patient Safety Goals and Associated Requirements by  Components and Practitioner Sites
        L. Application of Standards

XII. Encourage the Active Involvement of Patients and their Families in the Patient’s Care as Patient by Components and Practitioner Sites Is this correct as written?
        M. Lack of Family Involvement

XIII. Prevent Healthcare Associated Pressure Ulcers
        N. Pressure Ulcer

XIV. The Organization Identifies Safety Risks Inherent in its Patient Population
        O. Suicide risk

XV. Other
        P. Laboratory Test Problems
        Q. Radiology/Imaging Test Problem
        R. Transfusion
        S. Behavioral
        T. Care Coordination
        U. Staffing Related Problem:
                a. Cause of harm to patient
                b. Contributory causes to adverse outcomes

V. Physician Order Entry Related Problems
           W. Other Adverse Events


  

Index for Categorizing Medication Errors

The Index for Categorizing Medication Errors was based on the National Coordinating Council for Medication Error Reporting and Prevention.
Hicks, Rodney, Becker, Swan, Krenzischek, & Bayea, Suzanne.  (2004).  Medication errors in the PACU: a secondary analysis of Medmarx findings. Journal of PeriAnesthesia Nursing, 19(1): 18-28, February 2004.

Category A:  circumstances or events that have the capacity to cause error

Category B:  an error that occurred but did not reach the patient

Category C:  an error that occurred and did reach the patient but did not cause harm

Category D:  an error that occurred, reached the patient, and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm

Category E: an error that occurred which may have contributed to or resulted in temporary harm to the patient, and required intervention

Category F:  an error that occurred which may have contributed to or resulted in temporary harm to the patient, and required initial or prolonged hospitalization

Category G:  an error that occurred that may have contributed to or resulted in permanent patient harm

Category H:  an error that occurred which required intervention necessary to sustain life

Category I:  an error that occurred which may have contributed to or resulted in the patient's death

More medication-related safety information is available from the National Coordinating Council for Medication Error Reporting and Prevention www.nccmerp.org/medErrorCatIndex.html.

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