| Incident type |
Preventable |
Serious Error(Intercepted and non-intercepted) |
| Airway |
13 |
14 |
| Accidental Extubation/Decannulation |
03 |
0 |
| Blocked tube |
02 |
0 |
| Esophageal intubation |
01 |
02 |
| Bleeding from tracheostomy |
01 |
02 |
| Aspiration during intubation |
0 |
03 |
| Pilot balloon tubing of cuff accidently cut |
01 |
03 |
| Tooth dislodged |
01 |
00 |
| False passage during tracheostomy |
01 |
00 |
| Ventilator put on standby for suctioning,not switchedon afterwards |
00 |
04 |
| Attempted tracheostomy in ICU, failed due to retro-sternal goitre |
01 |
00 |
| Expiratory port of T tube blocked |
01 |
00 |
| Unnoticed Ventilator disconnection |
00 |
00 |
| Non-Airway related |
7 |
22 |
| Line related incidents |
| Ischaemia from arterial lines |
1 |
00 |
| Pneumothorax |
1 |
00 |
| Haemothorax |
1 |
00 |
| Failed to insert central line after multiple attempts |
2 |
06 |
| Arterial hits |
3 |
14 |
| Abnormal bleeding |
3 |
02 |
| Drug-related errors |
| Missed dose |
2 |
22 |
| Wrong dose |
8 |
26 |
| Wrong route |
1 |
04 |
| Not labelled, wrongly labeled |
0 |
02 |
| Wrong dilution |
01 |
01 |
| Delayed administration |
00 |
01 |
| Other medication error due to ordering or executionof treatment(LASA) |
0 |
0 |
| Dislodgements |
1 |
24 |
| Central venous catheters |
1 |
07 |
| Chest drains |
0 |
08 |
| Jejunal feeding tubings |
0 |
03 |
| Epidural Catheters |
0 |
02 |
| Abdominal drains |
0 |
04 |
