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 |