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Access
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DISCHARGE - DELAY/FAILURE
DISCHARGE- INAPPROPRIATE
DISCHARGE - REFUSAL
DISCHARGE PLANNING FAILURE
DISCHARGE SUMMARY DELAY
SELF DISCHARGE
FAILURE TO FOLLOW-UP
MISSED APPOINTMENT
FAILURE TO REFER
LACK OF/DELAYED AVAILABILITY OF BEDS (general)
LACK OF/DELAYED AVAILABILITY OF BEDS (high dep)
TRANSFER - DELAY/FAILURE
TRANSPORT INAPPROPRIATE
TRANSPORT - DELAY/FAILURE
OTHER

AccidentAccident
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CONTACTCONTACT WITHWITH ELECTRICITYELECTRICITY

EXPOSURE TO HARMFUL SUBSTANCE
Exposure to Radiation
Exposure to Asbestos
MOVING AND HANDLING
Moving & Handling - Patient/Positioni

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Moving & Handling - Non-patient

Moving & Handling - Display Screen
STRUCK BY FALLING OBJECT
CONTACT WITH HOT / COLD
STRUCK BY MOVING VEHICLE
SLIP/TRIP/FALL
Slip/Trip/Fall on same level
Slip/Trip/Fall from Height
ROAD TRAFFIC ACCIDENT
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CONTACT WITH FURNITURE/FITTINGS

OTHER
Building & Utility Issues

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DAMAGED WALL
DAMAGED FLOOR
PLUMBING LEAK
GAS LEAK
SEWAGE SMELL
DOOR LOCKED/NOT WORK PROPERLY
EQUIPMENT BROKEN
DOOR BROKEN
BLEEP SYSTEM FAILURE
FAILURE OF DEVICE/EQUIPMENT
DELAY/FAILURE TO PROVIDE EQUIPMENT TO USER

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IT/TELECOMMUNICATIONS FAILURE
LACK/UNAVAILABILITY OF DEVICE/EQUIPMENT
USER ERROR OF DEVICE/EQUIPMENT
WRONGWRONG DEVICEDEVICE OROR EQUIPMENTEQUIPMENT USE

DUSED
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INADEQUATE CHECK ON EQUIPMENT/SUPPLIES

FAILURE/DELAY IN COLLECTION/DELIVERY SYSTEMS
DEFECTIVE PRODUCT / SUPPLIES
FALLING OBJECT
OTHER
Clinical Assessment and Treatment

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DELAY/DIFFICULTY IN OBTAINING CLINICAL ASSISTANCE

DELAY OBTAINING BLEEP HOLDER OR ON-CALL STAFF
DIAGNOSIS - DELAY/FAILURE TO
LACK OF/DELAYED AVAILABILITY OF APPROPRIATE PHYSICI

AN
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DIAGNOSIS - WRONG
TREATMENT - DELAY/FAILURE IN RECOGNISING
TREATMENT - DELAY/FAILURE TO MONITOR
TREATMENT - FAILURE/INCORRECT
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TREATMENT - FAILURE TO DISCONTINUE

PATIENT INCORRECTLY IDENTIFIED
BLOOD TRANSFUSION REACTION
BLOOD / BLOOD COMPONENT TRANSFUSION ERROR
Incorrect Dispensing
Delay/Problem Obtaining Blood
SCANS/X-RAYS/SPECIMENS - INADEQUATE/INCOMPLETE
SCANS/X-RAYS/SPECIMENS - MISLABELLED/UNLABELLED
SCANS/X-RAYS/SPECIMENS - WRONG
SCANS/X-RAYS/SPECIMENS - MISSING
SCANS/X-RAYS/SPECIMENS - NOT READ
TEST REQUEST FORM - NONE/INCOMPLETE
TEST - FAILURE/DELAY TO UNDERTAKE
TEST RESULTS/REPORT - FAILURE/DELAY TO INTERPRET
TEST RESULTS/REPORT - INCORRECT
TEST RESULTS/REPORT - FAILURE/DELAY TO RECEIVE
TEST RESULTS/REPORT - MISSING
TEST RESULT/REPORT - MISLABELLED
DIETARYDIETARY ERRORERROR
Wrong Preparation
Wrong Diet
Food Hazard
Delay
DOCTOR'S INDUCED TREATMENT
NOT REFERRED TO SPECIFIC DOCTOR
CODE BLUE
SCISSORS LEFT IN DIAPERS
OTHER

Community
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DOG/RAT/HOUSEHOLD PETS/OTHERS

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STAFF LOCATION UNKNOWN

CAR BREAKDOWN
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UNHYGIENIC ENVIRONMENT
UNSAFE ENVIRONMENT
INADEQUATE SUPPORT
OTHER
DELAY/FAILURE TO PROVIDE SOCIAL CARE
DELAY/FAILURE OF CARE AGENCY TO PROVIDE CARE
FAILURE OF RESIDENTIAL CARE HOME TO PROVIDE CARE

Financial Issues
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WRONG COST ESTIMATION

DOUBLE CHARGED
TARIFF DIFFER BETWEEN THE BOOK AND IN THE SYSTEM
WRONG INPUT IN CHARGE SLIP
TRANSACTION NOT INPUTED
OTHER

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Fire Issues
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FIRE (inc. accidental)

FIREFIRE ALARMALARM FALSEFALSE
FIREFIRE ARSONARSON (MALICIOUS)(MALICIOUS)
DEFECTIVE FIRE EQUIPMENT
OTHER
Infection Control

FAILURE OF STERILISATION OR CONTAMINATION OF

FAILURE TO DECONTAMINATE EQUIPMENT
INFECTION - CROSS/HEALTHCARE ACQUIRED
INFECTION - WOUND
UNSAFE/INAPPROPRIATE CLINICAL ENVIRONMENT
UNSAFE/INAPPROPRIATE CLINICAL WASTE ISSUE
EXPOSURE TO BODILY FLUIDS
NEEDLESTICK INJURY
Dirty Needlestick Injury
Clean Needlestick Injury

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CUT BY SHARP OBJECT - NOT NEEDLESTICK

NOTIFIABLE DISEASE
OTHER

Information
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FAILURE TO OBTAIN CONSENT

HEALTHCARE RECORD NO ACCESS TO MEDICAL DOCUMENTATION

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CONFIDENTIALITY BREACH
INCORRECT MENTAL HEALTH ACT RECORDS
HEALTHCARE RECORD - DELAY IN OBTAINING
HEALTHCARE RECORD - MISLABELLED
HEALTHCARE RECORD - NOT SIGNED/DATED BY STAFF
HEALTHCARE RECORD - WRONG DELIVERY
CARE PLAN/ASSESSMENT REFERRAL - MISSING/INADEQUATE/ILLEGIBLE
APPOINTMENT RECORDING ERROR
DOCUMENTATION MISFILED
OTHEROTHER
IT Security

VIRUS ATTACK
ILLEGAL SOFTWARE
PASSWORD COMPROMISED
LOSS OF DATA
LOSS/THEFT OF IT EQUIPMENT
E-MAIL CONFIDENTIALITY BREACHED
INTERNET MISUSE
ANTI VIRUS EXPIRED
OTHER

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Maternity
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UNEXPECTED NEONATAL ADMISSION TO SCBU

BIRTH TRAUMA (other)
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DELAY IN PAEDIATRICIAN ARRIVING WITHIN 15 MINS OF

UNDIAGNOSED CONGENITAL ABNORMALITY
OTHER

Medication
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ILLEGIBLE PRESCRIPTION
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INCORRECT OR INAPPROPRIATE PRESCRIPTION
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NO SIGNATURE
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ALLERGY NOT RECORDED
6 Dispensing
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LABEL ERROR
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WRONG MEDICINE/STRENGTH
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WRONG QUANTITY
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DELAY/PROBLEM OBTAINING MEDICATION
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EXPIRED / DAMAGED MEDICINE
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WRONGWRONG PATIENTPATIENT
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WRONG MEDICINE
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Wrong dose
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WRONG FORMULATION
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WRONG FREQUENCY/RATE/TIME
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WRONG ROUTE
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MEDICINE OMITTED

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EXPIRED MEDICINE
ALLERGY RECORDED BUT TREATMENT GIVEN
NO RECORD OF ADMINISTRATION

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ADVERSE DRUG REACTION
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WRONG/OMITTED VERBAL OR WRITTEN ADVICE
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FAILURE TO MONITOR SIDE EFFECTS/THERAPY
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FAILURE PATIENT TO FOLLOW DIRECTIONS
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MEDICINES OBTAINED BY THEFT OR DECEPTION
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CONTROLLED DRUG ISSUE
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DELIVERY/TRANSPORT MEDICATION ISSUE
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INCORRECT STORAGE
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MEDICINES MISSING/UNACCOUNTED FOR
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MEDICINES FOUND LOOSE/NOT GIVEN
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MEDICINE KEY ISSUES
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LEFT UNATTENDED
37 Other
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PATIENT TRANSFERRED OR DISCHARGED WITH

MAR CHART OR MDS (E.G. DOSSETT) BOX ISSUE
INCORRECTLY IDENTIFIED
OTHER

Organisation
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ENVIRONMENTALENVIRONMENTAL ISSUEISSUE
Flooding
Oil Pollution
Effluent Pollution
Food Issue
SERVICE FAILURE (Lighting/Power/Heating etc.)
ON CALL SYSTEMS FAILURE
OTHER

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Security Issues
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INTRUDER
THEFT
Theft
Theft
Theft
Theft

of Staff Property
of Trust Property
of Patient Property
from/of Staff Vehicle
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Theft from/of Trust (loan) Vehicle

ABSCONDER/MISSING PERSON
VANDALISM

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UNSAFE ENVIRONMENT - (inc PERSONAL SAFETY)

LOST OR MISPLACED PROPERTY
BOGUS STAFF MEMBER
ACCIDENTAL DAMAGE
FRAUD OR DECEPTION
FORCED ENTRY
OTHER
SECURITY FALSE ALARM
Service Users Issues

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ALLERGIC REACTION
DEVELOPED PRESSURE SORES
Pressure ulcer developed within our care

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ESUSCITATE ORDERORDER
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Pressure ulcer acquired elsewhere

DELAY/FAILURE TO START CARDIO PULMONARY
CONCERNCONCERN OVEROVER AA DODO NOTNOT RESUSCITATER
UNEXPECTED OR SUSPICIOUS DEATH
ISSUE CONCERNING PATIENT DIGNITY
ALCOHOL AND ILLEGAL DRUGS USED
TOURNIQUET PROBLEM
CHAPERONE ISSUES
PATIENT SELF HARM
SUICIDE
SUICIDE ATTEMPTED
SUDDEN ONSET OF ILLNESS
INFUSION SITE
Swollen
Haematoma
OTHER

Staffing Issues
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INADEQUATE LEVELS
INADEQUATE SKILLS MIX
CONCERN OVER COMPETENCE
INADEQUATE SUPERVISION
ACTING BEYOND SCOPE OF PRACTICE
OTHER
Surgical / Theatre Issues

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THEATRE LIST DETAILS INCORRECT

LATE AMENDMENTS TO LIST
INCOMPLETE PRE-OPERATIVE PREPARATION OF
DIATHERMY BURN
TOURNIQUET PROBLEM
OPERATION SITE WRONGLY MARKED
WRONG OPERATION PERFORMED
INCORRECT SWAB OR INSTRUMENT COUNT
DEEP VEIN THROMBOSIS NO PROPHYLAXIS
UNPLANNED RETURN TO THEATRE
UNEXPECTEDUNEXPECTED ACUTEACUTE ADMISSIONADMISSION

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INCOMPLETE POST-OPERATIVE PREPARATION OF PATIENT

CARDIAC ARREST IN OT
DISCREPANCIES BETWEEN PREOPERATIVE AND POSTOPERATI

VE DIAGNOSES
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ADVERSE EVENTS DURING DEEP SEDATION OR ANESTHESIA

OTHER
Violence Issues

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FIREARMS/DANGEROUS WEAPONS
VERBAL (inc telephone)
by other
by patient
to staff by staff
PHYSICAL
by other
by patient
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to staff by
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Homicide by
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RACIAL
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by other
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by patient
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to staff by
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CHILD ABUSE Identified
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SEXUAL
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by other
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by patient
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to staff by
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BULLYING
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by other
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by patient
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to staff by
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ADULT ABUSE Identified
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OTHER (Specify)
Sumber: NPSA Incident Types, Categories and Sub-Categories

staff
Patient

staff

staff

staff

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