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Table 1 Distribution of Events by Event Types

From: Our first review: an evaluation of effectiveness of root cause analysis recommendations in Hong Kong public hospitals

 

Typea

Event

No.

%

1

SE

Surgery / interventional procedure involving the wrong patient or body part

8

4%

2

SE

Retained instruments or other material after surgery / interventional procedure

29

14%

3

SE

ABO incompatibility blood transfusion

1

0%

4

SE

Medication error resulting in major permanent loss of function or death

0

0%

5

SE

Intravascular gas embolism resulting in death or neurological damage

2

1%

6

SE

Death of an inpatient from suicide (including home leave)

15

7%

7

SE

Maternal death or serious morbidity associated with labour or delivery

4

2%

8

SE

Infant discharged to wrong family or infant abduction

2

1%

9

SE

Other adverse events (excluding complications) resulting in permanent loss of function or death

1

0%

10

SUE

Medication error which could have led to death or permanent harm

137

64%

11

SUE

Patient misidentification which could have led to death or permanent harm

15

7%

Total

214

100%

  1. aSE Sentinel Event; SUE Serious Untoward Event