A Taxonomy to Categorize Adverse Events and Near-Misses in Transport Medicine

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A Taxonomy to Categorize Adverse Events and Near-Misses in Transport Medicine by Mind Map: A Taxonomy to Categorize Adverse Events and Near-Misses in Transport Medicine

1. Appointment / Referral / Consultation

1.1. Not Performed when Indicated

1.2. Wrong Process / Service /

1.3. Wrong Patient

1.4. Unavailable

1.5. Incomplete / Inadequate

2. Handover to OCC Personnel

2.1. Incomplete / Inadequate

2.2. Unavailable

2.3. Wrong Patient

2.4. Wrong Process / Service

2.5. Not Performed when Indicated

3. Handover / Transfer of Care from Ornge Crew

3.1. Not Performed when Indicated

3.2. Incomplete / Inadequate

3.3. Unavailable

3.4. Wrong Patient

3.5. Wrong Process / Service

4. Handover / Transfer of Care to Ornge Crew

5. A. Incident type

5.1. Administration

5.1.1. Handover/transfer of care

5.1.1.1. Transfer type

5.1.1.1.1. From Ornge Care

5.1.1.1.2. To Ornge Crew

5.1.1.1.3. OCC Personnel/Dispatch

5.1.1.1.4. Appointment/Referral/ Consultation

5.1.1.2. Transfer Issue

5.1.1.2.1. Not Performed when Indicated

5.1.1.2.2. Incomplete / Inadequate

5.1.1.2.3. Unavailable

5.1.1.2.4. Wrong Patient

5.1.1.2.5. Wrong Process / Service

5.1.2. Patient Identification

5.1.2.1. Not Performed when Indicated

5.1.2.2. Incomplete / Inadequate

5.1.2.3. Unavailable

5.1.2.4. Wrong Patient

5.1.2.5. Wrong Process / Service

5.1.3. Consent

5.1.3.1. Not Performed when Indicated

5.1.3.2. Incomplete / Inadequate

5.1.3.3. Unavailable

5.1.3.4. Wrong Patient

5.1.3.5. Wrong Process / Service

5.1.4. Task Allocation

5.1.4.1. Not Performed when Indicated

5.1.4.2. Incomplete / Inadequate

5.1.4.3. Unavailable

5.1.4.4. Wrong Patient

5.1.4.5. Wrong Process / Service

5.1.5. Response to Emergency / Immediate Threat to Life

5.1.5.1. Not Performed when Indicated

5.1.5.2. Wrong Process / Service

5.1.5.3. Wrong Patient

5.1.5.4. Unavailable

5.1.5.5. Incomplete / Inadequate

5.1.6. Infection Control Barrier

5.1.6.1. Not Performed when Indicated

5.1.6.2. Incomplete / Inadequate

5.1.6.3. Unavailable

5.1.6.4. Wrong Patient

5.1.6.5. Wrong Process / Service

5.2. Process / Procedure

5.2.1. Clinical

5.2.1.1. Screening / Prevention / Routine Check

5.2.1.1.1. Not Performed when Indicated

5.2.1.1.2. Incomplete / Inadequate

5.2.1.1.3. Unavailable

5.2.1.1.4. Wrong Patient

5.2.1.1.5. Wrong Process / Treatment / Procedure

5.2.1.1.6. Wrong Body Part / Side / Site

5.2.1.1.7. Diagnosis / Assessment

5.2.1.1.8. Not Performed when Indicated

5.2.1.1.9. Incomplete / Inadequate

5.2.1.1.10. Unavailable

5.2.1.1.11. Wrong Patient

5.2.1.1.12. Wrong Process / Treatment / Procedure

5.2.1.1.13. Wrong Body Part / Side / Site

5.2.1.2. Procedure / Treatment / Intervention

5.2.1.2.1. Not Performed when Indicated

5.2.1.2.2. Incomplete / Inadequate

5.2.1.2.3. Unavailable

5.2.1.2.4. Wrong Patient

5.2.1.2.5. Wrong Process / Treatment / Procedure

5.2.1.2.6. Wrong Body Part / Side / Site

5.2.1.3. General Care / Management

5.2.1.3.1. Not Performed when Indicated

5.2.1.3.2. Incomplete / Inadequate

5.2.1.3.3. Unavailable

5.2.1.3.4. Wrong Patient

5.2.1.3.5. Wrong Process / Treatment / Procedure

5.2.1.3.6. Wrong Body Part / Side / Site

5.2.1.3.7. Tests / Investigations

5.2.1.3.8. Not Performed when Indicated

5.2.1.3.9. Incomplete / Inadequate

5.2.1.3.10. Unavailable

5.2.1.3.11. Wrong Patient

5.2.1.3.12. Wrong Process / Treatment / Procedure

5.2.1.3.13. Wrong Body Part / Side / Site

5.2.1.4. Specimens / Results

5.2.1.4.1. Not Performed when Indicated

5.2.1.4.2. Incomplete / Inadequate

5.2.1.4.3. Unavailable

5.2.1.4.4. Wrong Patient

5.2.1.4.5. Wrong Process / Treatment / Procedure

5.2.1.4.6. Wrong Body Part / Side / Site

5.2.1.5. Detention / Restraint

5.2.1.5.1. Not Performed when Indicated

5.2.1.5.2. Incomplete / Inadequate

5.2.1.5.3. Unavailable

5.2.1.5.4. Wrong Patient

5.2.1.5.5. Wrong Process / Treatment / Procedure

5.2.1.5.6. Wrong Body Part / Side / Site

5.2.2. Operational

5.2.2.1. Coding Patient in OCC

5.2.2.1.1. Launch Delay

5.2.2.1.2. Service Delay

5.2.2.1.3. Inadequate Equipment Communication

5.2.2.1.4. Refusal

5.2.2.1.5. Alternate Dispatch

5.2.2.1.6. No Consult with TMP

5.2.2.1.7. No Follow-up with Sending / Receiving

5.2.2.1.8. Improper Waste Disposal (Sharps, Biomedical, Hazardous Materials)

5.2.2.2. Coordination of OCC Calls

5.2.2.2.1. Launch Delay

5.2.2.2.2. Service Delay

5.2.2.2.3. Inadequate Equipment Communication

5.2.2.2.4. Refusal

5.2.2.2.5. Alternate Dispatch

5.2.2.2.6. No Consult with TMP

5.2.2.2.7. No Follow-up with Sending / Receiving

5.2.2.2.8. Improper Waste Disposal (Sharps, Biomedical, Hazardous Materials)

5.2.2.3. Screening OCC Calls

5.2.2.3.1. Launch Delay

5.2.2.3.2. Service Delay

5.2.2.3.3. Inadequate Equipment Communication

5.2.2.3.4. Refusal

5.2.2.3.5. Alternate Dispatch

5.2.2.3.6. No Consult with TMP

5.2.2.3.7. No Follow-up with Sending / Receiving

5.2.2.3.8. Improper Waste Disposal (Sharps, Biomedical, Hazardous Materials)

5.2.3. Documentation

5.2.3.1. Orders / Requests

5.2.3.1.1. Missing or Unavailable Document

5.2.3.1.2. Delay in Accessing Document

5.2.3.1.3. Wrong Patient

5.2.3.1.4. Unclear / Ambiguous / Illegible / Incomplete Information

5.2.3.1.5. Wrong Document

5.2.3.1.6. Delay in Completing Document

5.2.3.2. Charts / Medical Records / AACR / ePCR

5.2.3.2.1. Missing or Unavailable Document

5.2.3.2.2. Delay in Accessing Document

5.2.3.2.3. Wrong Patient

5.2.3.2.4. Unclear / Ambiguous / Illegible / Incomplete Information

5.2.3.2.5. Wrong Document

5.2.3.2.6. Delay in Completing Document

5.2.3.3. Checklists

5.2.3.3.1. Missing or Unavailable Document

5.2.3.3.2. Delay in Accessing Document

5.2.3.3.3. Wrong Patient

5.2.3.3.4. Unclear / Ambiguous / Illegible / Incomplete Information

5.2.3.3.5. Wrong Document

5.2.3.3.6. Delay in Completing Document

5.2.3.4. Forms / Certificates

5.2.3.4.1. Missing or Unavailable Document

5.2.3.4.2. Delay in Accessing Document

5.2.3.4.3. Wrong Patient

5.2.3.4.4. Unclear / Ambiguous / Illegible / Incomplete Information

5.2.3.4.5. Wrong Document

5.2.3.4.6. Delay in Completing Document

5.2.3.5. Instructions / Information / Policies / Procedures / Guidelines

5.2.3.5.1. Missing or Unavailable Document

5.2.3.5.2. Delay in Accessing Document

5.2.3.5.3. Wrong Patient

5.2.3.5.4. Unclear / Ambiguous / Illegible / Incomplete Information

5.2.3.5.5. Wrong Document

5.2.3.5.6. Delay in Completing Document

5.2.3.6. Labels / Stickers / Identification Bands / Cards

5.2.3.6.1. Missing or Unavailable Document

5.2.3.6.2. Delay in Accessing Document

5.2.3.6.3. Wrong Patient

5.2.3.6.4. Unclear / Ambiguous / Illegible / Incomplete Information

5.2.3.6.5. Wrong Document

5.2.3.6.6. Delay in Completing Document

5.2.3.7. Letters / e-Mails / Records of Communication

5.2.3.7.1. Missing or Unavailable Document

5.2.3.7.2. Delay in Accessing Document

5.2.3.7.3. Wrong Patient

5.2.3.7.4. Unclear / Ambiguous / Illegible / Incomplete Information

5.2.3.7.5. Wrong Document

5.2.3.7.6. Delay in Completing Document

5.2.3.8. Reports / Results / Images

5.2.3.8.1. Missing or Unavailable Document

5.2.3.8.2. Delay in Accessing Document

5.2.3.8.3. Wrong Patient

5.2.3.8.4. Unclear / Ambiguous / Illegible / Incomplete Information

5.2.3.8.5. Wrong Document

5.2.3.8.6. Delay in Completing Document

5.2.3.9. OCC Software / Resources*

5.2.3.9.1. Missing or Unavailable Document

5.2.3.9.2. Delay in Accessing Document

5.2.3.9.3. Wrong Patient

5.2.3.9.4. Unclear / Ambiguous / Illegible / Incomplete Information

5.2.3.9.5. Wrong Document

5.2.3.9.6. Delay in Completing Document

5.3. Medication / IV Fluids

5.3.1. Inventory Type

5.3.1.1. Ornge Rx scope list here

5.3.1.2. Other

5.3.2. Specific Occurrence

5.3.2.1. Prescribing

5.3.2.1.1. Wrong Patient

5.3.2.1.2. Wrong Drug

5.3.2.1.3. Wrong Dose / Strength or Frequency

5.3.2.1.4. Wrong Formulation or Presentation

5.3.2.1.5. Wrong Route

5.3.2.1.6. Wrong Quantity*

5.3.2.1.7. Wrong Dispensing Label / Instructions

5.3.2.1.8. Contraindication

5.3.2.1.9. Wrong Storage

5.3.2.1.10. Omitted Medicine or Dose

5.3.2.1.11. Expired Medicine

5.3.2.1.12. Adverse Drug Reaction / Effect

5.3.2.1.13. Wrong Time

5.3.2.2. Preparation / Dispensing

5.3.2.2.1. Wrong Patient

5.3.2.2.2. Wrong Drug

5.3.2.2.3. Wrong Dose / Strength or Frequency

5.3.2.2.4. Wrong Formulation or Presentation

5.3.2.2.5. Wrong Route

5.3.2.2.6. Wrong Quantity*

5.3.2.2.7. Wrong Dispensing Label / Instructions

5.3.2.2.8. Contraindication

5.3.2.2.9. Wrong Storage

5.3.2.2.10. Omitted Medicine or Dose

5.3.2.2.11. Expired Medicine

5.3.2.2.12. Adverse Drug Reaction / Effect

5.3.2.2.13. Wrong Time

5.3.2.3. Presentation / Packaging*

5.3.2.3.1. Wrong Patient

5.3.2.3.2. Wrong Drug

5.3.2.3.3. Wrong Dose / Strength or Frequency

5.3.2.3.4. Wrong Formulation or Presentation

5.3.2.3.5. Wrong Route

5.3.2.3.6. Wrong Quantity*

5.3.2.3.7. Wrong Dispensing Label / Instructions

5.3.2.3.8. Contraindication

5.3.2.3.9. Wrong Storage

5.3.2.3.10. Omitted Medicine or Dose

5.3.2.3.11. Expired Medicine

5.3.2.3.12. Adverse Drug Reaction / Effect

5.3.2.3.13. Wrong Time

5.3.2.4. Administration

5.3.2.4.1. Wrong Patient

5.3.2.4.2. Wrong Drug

5.3.2.4.3. Wrong Dose / Strength or Frequency

5.3.2.4.4. Wrong Formulation or Presentation

5.3.2.4.5. Wrong Route

5.3.2.4.6. Wrong Quantity*

5.3.2.4.7. Wrong Dispensing Label / Instructions

5.3.2.4.8. Contraindication

5.3.2.4.9. Wrong Storage

5.3.2.4.10. Omitted Medicine or Dose

5.3.2.4.11. Expired Medicine

5.3.2.4.12. Adverse Drug Reaction / Effect

5.3.2.4.13. Wrong Time

5.3.2.5. Supply / Ordering

5.3.2.5.1. Wrong Patient

5.3.2.5.2. Wrong Drug

5.3.2.5.3. Wrong Dose / Strength or Frequency

5.3.2.5.4. Wrong Formulation or Presentation

5.3.2.5.5. Wrong Route

5.3.2.5.6. Wrong Quantity*

5.3.2.5.7. Wrong Dispensing Label / Instructions

5.3.2.5.8. Contraindication

5.3.2.5.9. Wrong Storage

5.3.2.5.10. Omitted Medicine or Dose

5.3.2.5.11. Expired Medicine

5.3.2.5.12. Never Arrived / Lost In Transit

5.3.2.5.13. Adverse Drug Reaction / Effect

5.3.2.5.14. Wrong Time

5.3.2.5.15. Manufacturer Supply Issue

5.3.2.5.16. Pharmacy Supply Issue

5.3.2.5.17. Wrong Order

5.3.2.5.18. Damaged / Frozen Order

5.3.2.5.19. Incomplete Order

5.3.2.5.20. Order Delay

5.3.2.6. Storage

5.3.2.6.1. Wrong Patient

5.3.2.6.2. Wrong Drug

5.3.2.6.3. Wrong Dose / Strength or Frequency

5.3.2.6.4. Wrong Formulation or Presentation

5.3.2.6.5. Wrong Route

5.3.2.6.6. Wrong Quantity*

5.3.2.6.7. Wrong Dispensing Label / Instructions

5.3.2.6.8. Contraindication

5.3.2.6.9. Wrong Storage

5.3.2.6.10. Omitted Medicine or Dose

5.3.2.6.11. Expired Medicine

5.3.2.6.12. Adverse Drug Reaction / Effect

5.3.2.6.13. Wrong Time

5.3.2.6.14. Thermoreg issues

5.3.2.7. Monitoring

5.3.2.7.1. Wrong Patient

5.3.2.7.2. Wrong Drug

5.3.2.7.3. Wrong Dose / Strength or Frequency

5.3.2.7.4. Wrong Formulation or Presentation

5.3.2.7.5. Wrong Route

5.3.2.7.6. Wrong Quantity*

5.3.2.7.7. Wrong Dispensing Label / Instructions

5.3.2.7.8. Contraindication

5.3.2.7.9. Wrong Storage

5.3.2.7.10. Omitted Medicine or Dose

5.3.2.7.11. Expired Medicine

5.3.2.7.12. Adverse Drug Reaction / Effect

5.3.2.7.13. Wrong Time

5.4. Blood / Blood Products

5.4.1. Inventory Type

5.4.1.1. Clotting Factor

5.4.1.2. Cellular Products

5.4.1.3. Pentospan

5.4.1.4. Albumin / Plasma Protein

5.4.1.5. Immunoglobin

5.4.1.6. Other

5.4.2. Specific Occurrence

5.4.2.1. Pre-Transfusion Testing

5.4.2.1.1. Wrong Patient

5.4.2.1.2. Wrong Blood / Blood Product

5.4.2.1.3. Wrong Dose or Frequency

5.4.2.1.4. Wrong Quantity*

5.4.2.1.5. Wrong Dispensing Label / Instructions

5.4.2.1.6. Contraindication

5.4.2.1.7. Wrong Storage

5.4.2.1.8. Omitted Medicine or Dose

5.4.2.1.9. Expired Blood / Blood Product

5.4.2.1.10. Wrong Time

5.4.2.1.11. Adverse Drug Reaction / Effect

5.4.2.2. Prescribing

5.4.2.2.1. Wrong Patient

5.4.2.2.2. Wrong Blood / Blood Product

5.4.2.2.3. Wrong Dose or Frequency

5.4.2.2.4. Wrong Quantity*

5.4.2.2.5. Wrong Dispensing Label / Instructions

5.4.2.2.6. Contraindication

5.4.2.2.7. Wrong Storage

5.4.2.2.8. Omitted Medicine or Dose

5.4.2.2.9. Expired Blood / Blood Product

5.4.2.2.10. Wrong Time

5.4.2.2.11. Adverse Drug Reaction / Effect

5.4.2.3. Preparation / Dispensing

5.4.2.3.1. Wrong Patient

5.4.2.3.2. Wrong Blood / Blood Product

5.4.2.3.3. Wrong Dose or Frequency

5.4.2.3.4. Wrong Quantity*

5.4.2.3.5. Wrong Dispensing Label / Instructions

5.4.2.3.6. Contraindication

5.4.2.3.7. Wrong Storage

5.4.2.3.8. Omitted Medicine or Dose

5.4.2.3.9. Expired Blood / Blood Product

5.4.2.3.10. Wrong Time

5.4.2.3.11. Adverse Drug Reaction / Effect

5.4.2.4. Delivery*

5.4.2.4.1. Wrong Patient

5.4.2.4.2. Wrong Drug

5.4.2.4.3. Wrong Dose / Strength or Frequency

5.4.2.4.4. Wrong Formulation or Presentation

5.4.2.4.5. Wrong Route

5.4.2.4.6. Wrong Quantity*

5.4.2.4.7. Wrong Dispensing Label / Instructions

5.4.2.4.8. Contraindication

5.4.2.4.9. Wrong Storage

5.4.2.4.10. Omitted Medicine or Dose

5.4.2.4.11. Expired Medicine

5.4.2.4.12. Adverse Drug Reaction / Effect

5.4.2.4.13. Wrong Time

5.4.2.5. Administration

5.4.2.5.1. Wrong Patient

5.4.2.5.2. Wrong Drug

5.4.2.5.3. Wrong Dose / Strength or Frequency

5.4.2.5.4. Wrong Formulation or Presentation

5.4.2.5.5. Wrong Route

5.4.2.5.6. Wrong Quantity*

5.4.2.5.7. Wrong Dispensing Label / Instructions

5.4.2.5.8. Contraindication

5.4.2.5.9. Wrong Storage

5.4.2.5.10. Omitted Medicine or Dose

5.4.2.5.11. Expired Medicine

5.4.2.5.12. Adverse Drug Reaction / Effect

5.4.2.5.13. Wrong Time

5.4.2.6. Storage

5.4.2.6.1. Wrong Patient

5.4.2.6.2. Wrong Drug

5.4.2.6.3. Wrong Dose / Strength or Frequency

5.4.2.6.4. Wrong Formulation or Presentation

5.4.2.6.5. Wrong Route

5.4.2.6.6. Wrong Quantity*

5.4.2.6.7. Wrong Dispensing Label / Instructions

5.4.2.6.8. Contraindication

5.4.2.6.9. Wrong Storage

5.4.2.6.10. Omitted Medicine or Dose

5.4.2.6.11. Expired Medicine

5.4.2.6.12. Adverse Drug Reaction / Effect

5.4.2.6.13. Wrong Time

5.4.2.7. Monitoring*

5.4.2.7.1. Wrong Patient

5.4.2.7.2. Wrong Drug

5.4.2.7.3. Wrong Dose / Strength or Frequency

5.4.2.7.4. Wrong Formulation or Presentation

5.4.2.7.5. Wrong Route

5.4.2.7.6. Wrong Quantity*

5.4.2.7.7. Wrong Dispensing Label / Instructions

5.4.2.7.8. Contraindication

5.4.2.7.9. Wrong Storage

5.4.2.7.10. Omitted Medicine or Dose

5.4.2.7.11. Expired Medicine

5.4.2.7.12. Adverse Drug Reaction / Effect

5.4.2.7.13. Wrong Time

5.4.2.8. Presentation / Packaging

5.4.2.8.1. Wrong Patient

5.4.2.8.2. Wrong Drug

5.4.2.8.3. Wrong Dose / Strength or Frequency

5.4.2.8.4. Wrong Formulation or Presentation

5.4.2.8.5. Wrong Route

5.4.2.8.6. Wrong Quantity*

5.4.2.8.7. Wrong Dispensing Label / Instructions

5.4.2.8.8. Contraindication

5.4.2.8.9. Wrong Storage

5.4.2.8.10. Omitted Medicine or Dose

5.4.2.8.11. Expired Medicine

5.4.2.8.12. Adverse Drug Reaction / Effect

5.4.2.8.13. Wrong Time

5.4.2.9. Supply / Ordering (including labelling)

5.4.2.9.1. Wrong Patient

5.4.2.9.2. Wrong Drug

5.4.2.9.3. Wrong Dose / Strength or Frequency

5.4.2.9.4. Wrong Formulation or Presentation

5.4.2.9.5. Wrong Route

5.4.2.9.6. Wrong Quantity*

5.4.2.9.7. Wrong Dispensing Label / Instructions

5.4.2.9.8. Contraindication

5.4.2.9.9. Wrong Storage

5.4.2.9.10. Omitted Medicine or Dose

5.4.2.9.11. Expired Medicine

5.4.2.9.12. Adverse Drug Reaction / Effect

5.4.2.9.13. Wrong Time

5.5. Oxygen / Gas / Vapour

5.5.1. Inventory Type

5.5.1.1. Oxygen

5.5.1.2. Compressed Air

5.5.1.3. Helium

5.5.1.4. Nitric Oxide

5.5.1.5. Other

5.5.2. Specific Occurrence

5.5.2.1. Cylinder Labelling / Color Coding / PIN Indexing

5.5.2.1.1. Wrong Patient

5.5.2.1.2. Wrong Gas / Vapour

5.5.2.1.3. Wrong Rate / Flow / Concentration

5.5.2.1.4. Wrong Delivery Mode

5.5.2.1.5. Contraindication

5.5.2.1.6. Wrong Storage

5.5.2.1.7. Failure to Administer

5.5.2.1.8. Contamination

5.5.2.1.9. Insufficient / Inadequate Supply

5.5.2.2. Prescription / Directive / Order

5.5.2.2.1. Wrong Patient

5.5.2.2.2. Wrong Gas / Vapour

5.5.2.2.3. Wrong Rate / Flow / Concentration

5.5.2.2.4. Wrong Delivery Mode

5.5.2.2.5. Contraindication

5.5.2.2.6. Wrong Storage

5.5.2.2.7. Failure to Administer

5.5.2.2.8. Contamination

5.5.2.2.9. Insufficient / Inadequate Supply

5.5.2.3. Administration

5.5.2.3.1. Wrong Patient

5.5.2.3.2. Wrong Gas / Vapour

5.5.2.3.3. Wrong Rate / Flow / Concentration

5.5.2.3.4. Wrong Delivery Mode

5.5.2.3.5. Contraindication

5.5.2.3.6. Wrong Storage

5.5.2.3.7. Failure to Administer

5.5.2.3.8. Contamination

5.5.2.3.9. Insufficient / Inadequate Supply

5.5.2.4. Delivery*

5.5.2.4.1. Wrong Patient

5.5.2.4.2. Wrong Gas / Vapour

5.5.2.4.3. Wrong Rate / Flow / Concentration

5.5.2.4.4. Wrong Delivery Mode

5.5.2.4.5. Contraindication

5.5.2.4.6. Wrong Storage

5.5.2.4.7. Failure to Administer

5.5.2.4.8. Contamination

5.5.2.4.9. Insufficient / Inadequate Supply

5.5.2.5. Supply / Ordering

5.5.2.5.1. Wrong Patient

5.5.2.5.2. Wrong Gas / Vapour

5.5.2.5.3. Wrong Rate / Flow / Concentration

5.5.2.5.4. Wrong Delivery Mode

5.5.2.5.5. Contraindication

5.5.2.5.6. Wrong Storage

5.5.2.5.7. Failure to Administer

5.5.2.5.8. Contamination

5.5.2.5.9. Insufficient / Inadequate Supply

5.5.2.6. Storage

5.5.2.6.1. Wrong Patient

5.5.2.6.2. Wrong Gas / Vapour

5.5.2.6.3. Wrong Rate / Flow / Concentration

5.5.2.6.4. Wrong Delivery Mode

5.5.2.6.5. Contraindication

5.5.2.6.6. Wrong Storage

5.5.2.6.7. Failure to Administer

5.5.2.6.8. Contamination

5.5.2.6.9. Insufficient / Inadequate Supply

5.5.2.7. Securing During Transport

5.5.2.7.1. Wrong Patient

5.5.2.7.2. Wrong Gas / Vapour

5.5.2.7.3. Wrong Rate / Flow / Concentration

5.5.2.7.4. Wrong Delivery Mode

5.5.2.7.5. Contraindication

5.5.2.7.6. Wrong Storage

5.5.2.7.7. Failure to Administer

5.5.2.7.8. Contamination

5.5.2.7.9. Insufficient / Inadequate Supply

5.6. Medical Device / Equipment

5.6.1. Inventory Type

5.6.1.1. Generic List Here - i.e. Ventilator - LTV 1200

5.6.2. Specific Occurrence

5.6.2.1. Poor Presentation / Packaging

5.6.2.2. Lack of Availability

5.6.2.3. Inappropriate for Task

5.6.2.4. Unclean / Unsterile

5.6.2.5. Failure / Malfunction

5.6.2.6. Dislodgement / Misconnection / Removal

5.6.2.7. User Error

5.6.2.8. Expired

5.6.2.9. Assembly

5.6.2.10. Roles & Responsibilities

5.6.2.11. Pre Inspection

5.6.2.12. Maintenance Completion

5.6.2.13. Maintenance Effectiveness

5.6.2.14. Device Interaction

5.6.2.15. Electromagnetic / Radio frequency Interference

5.7. Patient/ Family Behaviour

5.7.1. Patient

5.7.1.1. Non-compliant / Uncooperative / Obstructive

5.7.1.2. Inconsiderate / Rude / Hostile / Inappropriate

5.7.1.3. Risky / Reckless / Dangerous

5.7.1.4. Problem with Substance Use / Abuse

5.7.1.5. Harassment

5.7.1.6. Discrimination / Prejudice

5.7.1.7. Wandering / Absconding

5.7.1.8. Intended Self Harm / Suicide

5.7.1.9. Verbal Aggression

5.7.1.10. Physical Assault

5.7.1.11. Sexual Assault

5.7.1.12. Aggression toward an Inanimate Object

5.7.1.13. Death Threat

5.7.2. Family

5.7.2.1. Non-compliant / Uncooperative / Obstructive

5.7.2.2. Inconsiderate / Rude / Hostile / Inappropriate

5.7.2.3. Risky / Reckless / Dangerous

5.7.2.4. Problem with Substance Use / Abuse

5.7.2.5. Harassment

5.7.2.6. Discrimination / Prejudice

5.7.2.7. Wandering / Absconding

5.7.2.8. Intended Self Harm / Suicide

5.7.2.9. Verbal Aggression

5.7.2.10. Physical Assault

5.7.2.11. Sexual Assault

5.7.2.12. Aggression toward an Inanimate Object

5.7.2.13. Death Threat

5.8. Patient Accidents While in Ornge Care

5.8.1. Blunt Force

5.8.1.1. Contact with Object or Animal

5.8.1.2. Contact with Person

5.8.1.3. Crushing

5.8.1.4. Abrading / Rubbing

5.8.2. Piercing / Penetrating Force

5.8.2.1. Scratching / Cutting / Tearing / Severing

5.8.2.2. Puncturing / Stabbing

5.8.2.3. Biting / Stinging / Invenomating

5.8.2.4. Other Specified Piercing / Penetrating Force

5.8.3. Other Mechanical Force

5.8.3.1. Struck by Explosive Blast

5.8.3.2. Contact with Machinery

5.8.4. Thermal Mechanism

5.8.4.1. Excessive Heat

5.8.4.2. Excessive Cooling

5.8.5. Threat to Airway

5.8.5.1. Mechanical Threat to Airway (such as extubation)

5.8.5.2. Threat to Breathing

5.8.5.3. Mechanical Threat to Breathing

5.8.5.4. Drowning / Near Drowning

5.8.5.5. Confinement to Oxygen-Deficient Place

5.8.6. Threat to Circulation

5.8.7. Exposure to Chemical or Other Substance

5.8.7.1. Poisoning by Chemical or Other Substance

5.8.7.2. Corrosion by Chemical or Other Substance

5.8.8. Other Specified Mechanism of Injury

5.8.8.1. Exposure to Electricity / Radiation

5.8.8.2. Exposure to Sound / Vibration

5.8.8.3. Exposure to Air Pressure

5.8.8.4. Exposure to Low Gravity

5.8.8.5. Exposure to (Effect of) Weather, Natural Disaster, or Other Force of Nature

5.9. Resources / Organizational Management

5.9.1. Alignment of Workload Management - hours of work, # of calls, acuity, work scheduling

5.9.2. Service Availability / Adequacy (Ornge)

5.9.3. Human Resource / Staff Availability / Adequacy / Levels

5.9.4. Organization of Teams / People

5.9.5. Protocols / Policy / Procedure / Guideline Availability / Adequacy

5.9.6. External Resources

5.10. Organ Donation

5.10.1. Service Availability / Adequacy

5.10.2. Human Resource / Staff Availability / Adequacy

5.10.3. Organization of Teams / People

5.10.4. Protocols / Policy / Procedure / Guideline Availability / Adequacy

5.11. Ornge Bases / Vehicles

5.11.1. Facility Damage

5.11.1.1. Fire

5.11.1.2. Explosion

5.11.1.3. Flood

5.11.1.4. Weather

5.11.1.5. Environmental (i.e. spills)

5.11.1.6. Civil Unrest

5.11.1.7. Security

5.11.1.8. Animal Encounter

5.11.1.9. Theft

5.11.1.10. Loss of Essential Service (power, natural gas, electricity, water, communications, heat, air conditioning, fire suppression system)

5.11.2. Facilities Inventory Type

5.11.2.1. Ottawa - CCLT

5.11.2.2. Ottawa - Rotor

5.11.2.3. Sudbury - Barrydowne Office

5.11.2.4. Sudbury - Rotor

5.11.2.5. Thunder Bay - Superbase

5.11.2.6. Thunder Bay - Rotor

5.11.2.7. Hamilton - Superbase

5.11.2.8. Toronto - Rotor

5.11.2.9. Toronto - CCLT

5.11.2.10. Mississsauga - Explorer

5.11.2.11. Toronto - Carlson Crt

5.11.2.12. Peterborough - CCLT

5.11.2.13. London - Rotor

5.11.2.14. Kenora - Rotor

5.11.2.15. Moosonee - Rotor

5.11.2.16. Moosonee - Crew House

5.11.2.17. Timmins - Fixed

5.11.2.18. Sioux Lookout - Fixed

5.11.3. Vehicle Damage

5.11.3.1. Fire

5.11.3.2. Explosion

5.11.3.3. Weather

5.11.3.4. Civil Unrest

5.11.3.5. Theft

5.11.3.6. Motor Vehicle Crash

5.11.4. Vehicle Inventory Type

5.11.4.1. 2006 CHEVY TAHOE - 1GNEK13Z06J158882

5.11.4.2. 2006 FORD ECONO E350 CUTAWAY - 1FDWE35P96HB35583

5.11.4.3. Simulation Trailer (ATM)

5.11.4.4. 2007 Chevrolet CUTVN - 1GBJG31U271217965

5.11.4.5. 2007 Chevrolet CUTVN - 1GBJG31U271218114

5.11.4.6. 2007 Chevrolet CUTVN - 1GBJG31UX71217583

5.11.4.7. 2007 Chevrolet CUTVN - 1GBJG31U571218463

5.11.4.8. 2007 Chevrolet CUTVN - 1GBJG31U071218483

5.11.4.9. 2007 Chevrolet CUTVN - 1GBJG31U871218800

5.11.4.10. 2007 Chevrolet CUTVN - 1GBJG31UO71217902

5.11.4.11. 2007 Chevrolet CUTVN - 1GBJG31U371218834

5.11.4.12. 2007 Chevrolet CUTVN - 1GBJG31U871218358

5.11.4.13. 2007 Chevrolet CUTVN - 1GBJG31U471218499

5.11.4.14. 2007 Chevrolet CUTVN - 1GBJG31U271215861

5.11.4.15. 2007 Chevrolet CUTVN - 1GBJG31U671218200

5.11.4.16. 2007 Chevrolet CUTVN - 1GBJG31UX71218412

5.11.4.17. 2007 Chevrolet CUTVN - 1GBJG31U071252214

5.11.4.18. 2007 Chevrolet CUTVN - 1GBJG31U971215775

5.11.4.19. 2007 Chevrolet CUTVN - 1GBJG31U271251906

5.11.4.20. 2007 Chevrolet CUTVN - 1GBJG31U171215575

5.11.4.21. 1997 Ford CVS - 1FDJS34F5VHA49066

6. B. Patient Outcomes

6.1. Pathophysiology / Type of Harm

6.1.1. Blood and Lymphatic Disorders

6.1.1.1. None

6.1.1.2. Mild

6.1.1.3. Moderate

6.1.1.4. Severe

6.1.1.5. Death

6.1.2. Cardiac Disorders

6.1.2.1. None

6.1.2.2. Mild

6.1.2.3. Moderate

6.1.2.4. Severe

6.1.2.5. Death

6.1.3. Congenital, Family, and Genetic Disorders

6.1.3.1. None

6.1.3.2. Mild

6.1.3.3. Moderate

6.1.3.4. Severe

6.1.3.5. Death

6.1.4. Ear and Labyrinth Disorders

6.1.4.1. None

6.1.4.2. Mild

6.1.4.3. Moderate

6.1.4.4. Severe

6.1.4.5. Death

6.1.5. Endocrine Disorders

6.1.5.1. None

6.1.5.2. Mild

6.1.5.3. Moderate

6.1.5.4. Severe

6.1.5.5. Death

6.1.6. Eye Disorders

6.1.6.1. None

6.1.6.2. Mild

6.1.6.3. Moderate

6.1.6.4. Severe

6.1.6.5. Death

6.1.7. Gastrointestinal Disorders

6.1.7.1. None

6.1.7.2. Mild

6.1.7.3. Moderate

6.1.7.4. Severe

6.1.7.5. Death

6.1.8. Hepatobiliary Disorders

6.1.8.1. None

6.1.8.2. Mild

6.1.8.3. Moderate

6.1.8.4. Severe

6.1.8.5. Death

6.1.9. Immune System Disorders

6.1.9.1. None

6.1.9.2. Mild

6.1.9.3. Moderate

6.1.9.4. Severe

6.1.9.5. Death

6.1.10. Infections and Infestations

6.1.10.1. None

6.1.10.2. Mild

6.1.10.3. Moderate

6.1.10.4. Severe

6.1.10.5. Death

6.1.11. Poisoning and Ingestion

6.1.11.1. None

6.1.11.2. Mild

6.1.11.3. Moderate

6.1.11.4. Severe

6.1.11.5. Death

6.1.12. Investigations

6.1.12.1. None

6.1.12.2. Mild

6.1.12.3. Moderate

6.1.12.4. Severe

6.1.12.5. Death

6.1.13. Metabolism and Nutrition Disorders

6.1.13.1. None

6.1.13.2. Mild

6.1.13.3. Moderate

6.1.13.4. Severe

6.1.13.5. Death

6.1.14. Musculoskeletal and Connective Tissue Disorders

6.1.14.1. None

6.1.14.2. Mild

6.1.14.3. Moderate

6.1.14.4. Severe

6.1.14.5. Death

6.1.15. Neoplasms Benign, Malignant, and Unspecified

6.1.15.1. None

6.1.15.2. Mild

6.1.15.3. Moderate

6.1.15.4. Severe

6.1.15.5. Death

6.1.16. Nervous System Disorders

6.1.16.1. None

6.1.16.2. Mild

6.1.16.3. Moderate

6.1.16.4. Severe

6.1.16.5. Death

6.1.17. Pregnancy, Puerperium, and Perinatal Conditions

6.1.17.1. None

6.1.17.2. Mild

6.1.17.3. Moderate

6.1.17.4. Severe

6.1.17.5. Death

6.1.18. Psychiatric Disorders

6.1.18.1. None

6.1.18.2. Mild

6.1.18.3. Moderate

6.1.18.4. Severe

6.1.18.5. Death

6.1.19. Renal and Urinary Disorders

6.1.19.1. None

6.1.19.2. Mild

6.1.19.3. Moderate

6.1.19.4. Severe

6.1.19.5. Death

6.1.20. Reproductive Systems and Breast Disorders

6.1.20.1. None

6.1.20.2. Mild

6.1.20.3. Moderate

6.1.20.4. Severe

6.1.20.5. Death

6.1.21. Respiratory, Thoracic, and Mediastinal Disorders

6.1.21.1. None

6.1.21.2. Mild

6.1.21.3. Moderate

6.1.21.4. Severe

6.1.21.5. Death

6.1.22. Skin and Subcutaneous Tissue Disorders

6.1.22.1. None

6.1.22.2. Mild

6.1.22.3. Moderate

6.1.22.4. Severe

6.1.22.5. Death

6.1.23. Social Circumstances

6.1.23.1. None

6.1.23.2. Mild

6.1.23.3. Moderate

6.1.23.4. Severe

6.1.23.5. Death

6.1.24. Surgical and Medical Procedures

6.1.24.1. None

6.1.24.2. Mild

6.1.24.3. Moderate

6.1.24.4. Severe

6.1.24.5. Death

6.1.25. Vascular Disorders

6.1.25.1. None

6.1.25.2. Mild

6.1.25.3. Moderate

6.1.25.4. Severe

6.1.25.5. Death

6.1.26. Procedural Complications

6.1.26.1. None

6.1.26.2. Mild

6.1.26.3. Moderate

6.1.26.4. Severe

6.1.26.5. Death

6.1.27. Injury or Trauma

6.1.27.1. None

6.1.27.2. Mild

6.1.27.3. Moderate

6.1.27.4. Severe

6.1.27.5. Death

7. C. Patient Characteristics

7.1. Age

7.1.1. __ Years

7.1.2. [checkbox] if <1 # months

7.2. Gender

7.2.1. Male

7.2.2. Female

7.2.3. Unknown

7.3. Primary Diagnosis

7.3.1. Refer to section B. Pt Outcomes for chart

7.4. Reason for Transport

7.4.1. On Scene Response

7.4.2. Modified On Scene Response

7.4.3. Interfacility Response

8. D. Incident Characteristics

8.1. Priority of Transport

8.1.1. emergent

8.1.2. urgent

8.1.3. non-urgent

8.1.4. scheduled

8.2. Phase of Treatment or Transfer

8.3. Care Setting

8.3.1. Hospital

8.3.2. Other

8.3.3. Scene

8.3.4. Nursing Station

8.3.5. Airport

8.3.6. Medical Transport Service

8.3.7. Helipad / Heliport

8.3.8. Patient Holding Area

8.3.9. Rotor Wing Aircraft

8.3.10. Fixed Wing Aircraft

8.3.11. Commercial Airline

8.3.12. Fixed Wing Aircraft - Non Ornge (Standing Agreement)

8.3.13. Land Vehicle - Ornge

8.3.14. Land Vehicle - Non Ornge

8.3.15. Base - Ornge

8.3.16. Base - Non Ornge

8.3.17. OCC

8.3.18. Ornge Head Office

8.4. Disciplines Involved

8.4.1. Non Ornge Personnel

8.4.1.1. Liaison Officer

8.4.1.2. Patient Transport / Retrieval Personnel

8.4.1.3. Clerical / Administrative Personnel

8.4.1.4. Service Personnel

8.4.1.5. Interpreter / Translator

8.4.1.6. Technical / Laboratory Personnel

8.4.1.7. Pastoral Care Personnel

8.4.1.8. Biomedical Engineer

8.4.1.9. Other

8.4.1.10. Nurse

8.4.1.11. Doctor

8.4.1.12. Pharmacist

8.4.1.13. Occupational Therapist

8.4.1.14. Dentist

8.4.1.15. Nurse Practitioner

8.4.1.16. Physician Assistant

8.4.1.17. Student / Trainee

8.4.1.18. Other

8.4.1.19. Assistant / Orderly

8.4.1.20. Pilot

8.4.1.21. Fueller

8.4.1.22. Aviation Maintenance / Engineer

8.4.1.23. Air traffic Control

8.4.1.24. Criticall Personnel

8.4.1.25. MoH-EHS Personnel

8.4.1.26. Trillium Gift of Life Personnel

8.4.1.27. Police Officer

8.4.1.28. Fire Fighter

8.4.1.29. CACC Personnel

8.4.1.30. Paramedic

8.4.1.31. Physiotherapist

8.4.1.32. Laboratory Technologist

8.4.1.33. Radidiagnostic Technologist

8.4.1.34. Laboratory Technologist

8.4.1.35. Aviation - Flight Personnel

8.4.1.36. Aviation - Other Personnel

8.4.1.37. Local Health Integrated Network (LHIN)

8.4.2. Ornge Personnel

8.4.2.1. Aviation - Flight Personnel

8.4.2.2. Aviation - Maintenance Personnel

8.4.2.3. Aviation - Other Personnel

8.4.2.4. Paramedic / RN

8.4.2.5. OCC Personnel

8.4.2.6. Other

8.4.2.7. Medical Director / Transport Medicine Physician

8.4.2.8. Office / Support Personnel

8.5. Person Reporting

8.5.1. Patient / Relative / Volunteer / Carer / Home Assistant

8.5.1.1. Patient

8.5.1.2. Another Patient

8.5.1.3. Relative / Guardian

8.5.1.4. Friend / Visitor

8.5.1.5. Volunteer

8.5.1.6. Carer / Home Aid / Assistant

8.5.1.7. Other

8.5.2. Ornge Personnel

8.5.2.1. Aviation - Flight Personnel

8.5.2.2. Aviation - Maintenance Personnel

8.5.2.3. Aviation - Other Personnel

8.5.2.4. Paramedic / RN

8.5.2.5. OCC Personnel

8.5.2.6. Other

8.5.2.7. Medical Director / Transport Medicine Physician

8.5.2.8. Office / Support Personnel

8.5.3. Non Ornge Personnel

8.5.3.1. Liaison Officer

8.5.3.2. Patient Transport / Retrieval Personnel

8.5.3.3. Clerical / Administrative Personnel

8.5.3.4. Service Personnel

8.5.3.5. Interpreter / Translator

8.5.3.6. Technical / Laboratory Personnel

8.5.3.7. Pastoral Care Personnel

8.5.3.8. Biomedical Engineer

8.5.3.9. Other

8.5.3.10. Nurse

8.5.3.11. Doctor

8.5.3.12. Pharmacist

8.5.3.13. Occupational Therapist

8.5.3.14. Dentist

8.5.3.15. Nurse Practitioner

8.5.3.16. Physician Assistant

8.5.3.17. Student / Trainee

8.5.3.18. Other

8.5.3.19. Assistant / Orderly

8.5.3.20. Pilot

8.5.3.21. Fueller

8.5.3.22. Aviation Maintenance / Engineer

8.5.3.23. Air traffic Control

8.5.3.24. Criticall Personnel

8.5.3.25. MoH-EHS Personnel

8.5.3.26. Trillium Gift of Life Personnel

8.5.3.27. Police Officer

8.5.3.28. Fire Fighter

8.5.3.29. CACC Personnel

8.5.3.30. Paramedic

8.5.3.31. Physiotherapist

8.5.3.32. Laboratory Technologist

8.5.3.33. Radidiagnostic Technologist

8.5.3.34. Laboratory Technologist

8.5.3.35. Aviation - Flight Personnel

8.5.3.36. Aviation - Other Personnel

8.5.3.37. Local Health Integrated Network (LHIN)

8.6. People Involved

8.6.1. Please refer to c. Disciplines involved and pt/relative ...

9. E. Contributing Factors / Hazards

9.1. Staff Factors

9.2. Patient Factors

9.2.1. Adequate Care / Support Provision

9.2.2. Patient Education / Training Provision

9.2.3. Protocols / Decision Support Provision

9.2.4. Monitoring Equipment Provision

9.2.5. Medication Dispensing Aid Provision

9.3. Work / Environment Factors

9.3.1. Physical Environment / Infrastructure

9.3.2. Remote / Long Distance from Service

9.3.3. Environmental Risk Assessment / Safety Evaluation

9.3.4. Current Code / Specifications / Regulations

9.4. Organizational / Service Factors

9.4.1. Protocols / Policies / Procedure / Processes

9.4.2. Organizational Decisions / Culture

9.4.3. Discipline / Service

9.4.4. Organization of Teams

9.4.5. Emergency / Excavation / Disaster Plan

9.4.6. Resources / Workload

9.5. External Factors

9.5.1. Natural Environment

9.5.2. Products, Technology & Infrastructure

9.5.3. Services, Systems & Policies

9.5.4. Stakeholder Expectations

9.6. Mitigating Factors

9.6.1. Directed to Patient

9.6.1.1. Help Called For

9.6.1.2. Management / Treatment / Care Undertaken

9.6.1.3. Patient Referred

9.6.1.4. Patient Education / Explanation

9.6.1.5. Apology

9.6.2. Directed to Staff

9.6.2.1. Good Supervision / Leadership

9.6.2.2. Good Team Work

9.6.2.3. Effective Communication

9.6.2.4. Relevant Person(s) Attended

9.6.2.5. Relevant Person(s) Educated

9.6.2.6. Good Luck / Chance

9.6.3. Directed to Organization

9.6.3.1. Effective Protocol Available

9.6.3.2. Product / Equipment / Device Management & Availability / Accessibility

9.6.3.3. Documentation Error Corrected

9.6.4. Directed to an Agent

9.6.4.1. Security / Physical Environment Measure

9.6.4.2. Infection Control Strategies Managed / Implemented

9.6.4.3. Therapeutic Agent Error Corrected

9.6.4.4. Equipment Usage Error Corrected

9.6.5. Other

9.6.5.1. Security / Physical Environment Measure

9.6.5.2. Infection Control Strategies Managed / Implemented

9.6.5.3. Therapeutic Agent Error Corrected

9.6.5.4. Equipment Usage Error Corrected

10. F. Error Recognition / Detection

10.1. Patient's Status Change

10.2. Machine / System / Environment / Change / Alarm

10.3. Count / Audit / Review

10.4. Proactive Risk Assessment

11. G. Organizational Outcomes

11.1. Property Damage

11.2. Increased Resource Allocation

11.2.1. Length of Patient Contact - Increased

11.2.2. Level of Care - Modified

11.2.3. Treatment / Tests - Additional

11.2.4. Workflow Disruption / Delays for Other Patients

11.2.5. Additional Staff Required

11.2.6. Equipment Required - Additional

11.2.7. Supplementary Transport Vehicle Required

11.3. Media Attention

11.4. Formal Complaint

11.5. Reputation Damaged

11.6. Legal Ramifications

12. H. Restitution / Rectifying Actions

12.1. Patient Related

12.1.1. Disease / Disorder Management

12.1.2. Management of Injury Management*

12.1.3. Disability Management

12.1.4. Compensation

12.1.5. Open Disclosure / Apology

12.2. Organizational Related

12.2.1. Media Management / Public Relations

12.2.2. Complaint Management

12.2.3. Claims / Risk Management

12.2.4. Stress Debriefing / Staff Counselling

12.2.5. Local Notification and Restitution

12.2.6. Reconciliation / Mediation

12.2.7. Culture Change

12.2.8. Education / Training

13. I. Actions to Reduce Risk

13.1. Patient Factors

13.1.1. Adequate Care / Support Provision

13.1.2. Patient Education / Training Provision

13.1.3. Protocols / Decision Support Provision

13.1.4. Monitoring Equipment Provision

13.1.5. Medication Dispensing Aid Provision

13.2. Staff Factors

13.2.1. Training

13.2.2. Orientation

13.2.3. Supervision / Assistance

13.2.4. Fatigue Management Strategies

13.2.5. Availability of Checklists / Protocols / Policies

13.2.6. Adequate Staff Numbers / Quality

13.3. Organizational / Environmental Factors

13.3.1. Physical Environment to Needs Matching

13.3.2. Access to a Service Arrangements

13.3.3. Risk Assessment / Root Cause Analyses Performance

13.3.4. Current Code / Specifications / Regulations Being Met

13.3.5. Ready Access to Protocols / Policies / Decision Support Arranging

13.3.6. Leadership / Guidance Improvement

13.3.7. Staff to Tasks / Skills Matching

13.3.8. Safety Culture Improvement

13.4. Agent / Equipment Factors

13.4.1. Equipment Provision

13.4.2. Forcing Functions

13.4.3. Regular Audits