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Slide Presentation from the AHRQ 2007 Annual Conference

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Example Report (continued)

Text Description is below the image.

Continuation of the example report begun on Slide 16.

Wrong medication administered Medication Error Wrong drug name 2 2.1 2.66% 0.21-2.82 2.05%
Wrong dose of drug Medication Error Wrong dose 2 2.1 2.66% 0-2.24 1.29%
Adverse drug reaction Adverse Drug Reaction Any adverse drug reaction such as skin rash, vomiting, or hypotension 0 0 0% 0-0.59 1.67%
Patient misidentification Admission Discharge Transfer Wrong patient, more than one ID, or incorrect ID bracelet 2 2.1 2.66% 0-2.48 2.24%
Specimen Wrong label or specimen obtained from wrong patient
Surgery Invasive Procedure Wrong patient
Treatment Wrong patient
Medication Error Order written, transcribed, dispensed or administered to the wrong patient
Blood Transfusion Order written, transcribed, dispensed or administered to the wrong patient
Total number of events reported 42 2097

Notes:

Total number of events reported—Represents total number of events in the ORM system and will not be the sum of events in the report indicators
Percent of events—percent of events that fell into an event category. Since not all events are in a category. The sum of percents will not add to 100%.

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