“I” events: 18

Definition: event or error that contributed to or resulted in unexpected death

2 CPR in the emergency department

3 CPR in surgery

2 review of death in emergency department

1 terminal patient died while in surgery

1 lack of communication between hospitalist and emergency department physician

1 patient death while boarding in emergency department

1 ruptured appendix resulted in death

1 baby death before delivery

1 difference in CT readings after patient died

1 error in treatment resulted in death

1 fall due to clinical frailty, patient eventually died

1 response time to CPR

1 baby death during delivery

1 patient died while in CT

“H” events: 8

Definition: event or error that required intervention necessary to sustain life

2 patient deterioration events

1 incomplete handoff

1 arrest while boarding in emergency department

1 change in medication

1 fall

1 incorrect dosage given

1 error in O2 and humidified air provided during CPR

“G” events: 15

Definition: event or error that may have contributed to or resulted in permanent harm

10 falls

1 delay in transfer

1 misdiagnosis in pathology

1 perceived lack of treatment caused damage

1 patient went into arrest and transferred to ICU

1 patient given incorrect medication