| Pressure sore | Partial injury of skin and subcutaneous tissue, usually happened in bone carina, caused by pressure or/and shear force in general | Part and classification, nosocomial happening, history of pressure sore, action ability, risk assessment, ADL grade, accompanist, measures taken before event happening. | Systematic factors: average number of patients nurses in this ward taking care of. | Patient's factors: stay in bed, hormone used, hypoproteinemia, dyspraxia, anemia, obesity, edema, diarrhea, gatism, urinary catheter indwelling, forced position, infection, coma, skin feeling injury, restraint, operation, pressure dressing. | Medical staff factors: turning over, skin cleaning, catheter fixation, nursing equipment used. | Environmental factors: bed cleaning. | Pressure sore development, further treatment received. |
| Fall/falling from bed | Falling: Influenced by internal and external factors, one couldn’t maintain his erect posture due to posture change or function failure, and fall down to floor or lower plane. Falling from bed: According to sudden, involuntary and unintentional position change, one fall from bed. | Place, history of fall/falling from bed, accompanist, risk assessment, ADL grade, pain assessment, measures taken before event happening | Systematic factors: number of patients the nurse taking care of, nurse's training of relative knowledge. | Patient's factors: mental state, conscious state, state when falling happened, disease, drug, action ability. | Medical staff factors: health education, help patients who were bad in action, bedside rail used. | Environmental factors: ponding, slippery floor, uneven ground, too many barriers, lines placed randomly by patients or their relatives, bed overtopped, bed's brake unfixed, inappropriate light, lack of handrail, lack of warning sign, warning sign failed to work. | Injury part, uncomfortable complain, soft tissue injury, fracture/dislocation, craniocerebral injury, disability or death, further treatment received in other medical organizations. |
| Unplanned extubation | Extubation or catheter shifting without medical staff agreement, including extubation caused by inappropriate operation. | Place, catheterizing time, type of catheters, history of unplanned extubation, situation when unplanned extubation happened, way of fixing, accompanist, ADL grade, pain assessment. | Systematic factors: number of patients the nurse taking care of, nurse's training of relative knowledge, air sac or water sac rupture, suture breakage, defective operation procedure. | Patient's factors: mental state, conscious state, drug, restraint, extubation while getting rid of restraint, extubation when patient's relatives didn’t understand, patient with cognitive impairment extubated himself, extubation when couldn’t tolerant uncomfortable catheterizing, forced position, extubation while sneezing or vomiting, catheters stretched. | Medical staff factors: restrain in time, catheters inappropriate fixed, catheters stretched, health education. | Environmental factors: catheters twined. | Drug extravasation, skin and mucosa injury, tube plugging, bleeding, asphyxia, pneumothorax, air embolism, thrombus, catheterizing again, anastomotic fistula, operation or rescue, infection, disability or death, further treatment received in other medical organizations. |
| Medication error | Drug patients received actually wasn’t the same as the one according to doctor's order, which was caused by nurses. Medication error include wrong drug type, medication time, dose, administration route, patient, etc. | Drug name by doctor's order, wrong drug, wrong medication time, wrong dose, wrong administration route, wrong patients, wrong medication frequency, wrong infusion speed, wrong dosage, wrong drug concentration, drug administration when lack of doctor's order, implemented doctor's oral order when not a rescue, past-due drug, implemented stopped doctor's order, drug missing. | Systematic factors: number of patients the nurse taking care of, nurse's training of relative knowledge, lack of drug use warning in information system, wrong or unclear drug label, similar drug names, similar drug packaging, similar drug shapes, drug dispensing machine out of order, mobile nursing system out of order, unclear writing of requisition for drugs due to overmuch check, easily confused drug placed together with no electronic medicine cabinet. | | Medical staff factors: unclear writing, incomplete doctor's order, incomplete printing of doctor's order sheet, misheard when implemented doctor's oral order, misread order, misunderstood order, wrong administration, wrong dispensing, unable to use medication machines, order without double check, invalid medication information shift, expensive or poison anesthetic drug missing due to cabinet unlocked, drug out of date due to no timely check, wrong pasted drug label. | Environmental factors: easily confused drug placed together in electronic medicine cabinet, lack of warning sign for easily confused drug, drug missing as to drug and other things were put together. | Uncomfortable complain, drug reaction, rescue, disability or death, further treatment received in other medical organizations. |
| Accident | Unusual treatment; sudden, hard to guard against and harm to individual action, which happened during patient's treatment in hospital, e.g., scald, irritant drug extravasation, aspiration. | Place, accompanist, body disability, language expression difficulty, number of patients the nurse taking care of, nurse's training of relative knowledge, equipment out of order. | Events like burn, scald, drug extravasation/phlebophlogosis, restraint accident, aspiration, blood transfusion error, electrical lesion, suicide/autolesion have their own event description and reason analysis. | Uncomfortable complain, skin injury, nerve injury, limbs ischemia and necrosis, fracture, asphyxia, infection, operation or rescue, disability or death, further treatment received in other medical organizations. |
