Table 2

The triggers we identified in our study are presented with PPV with 95% CI for identifying harm

ItemPPV (CI)%
General care
 PG1 Early warning score
 PG2 Tissue damage or pressure ulcer
 PG3 Readmission within 30 days24/175=14 (9 to 20)
 PG4 Unplanned admission
 PG5 Abnormal cranial imaging
 PG6 Respiratory or cardiac arrest/crash calls0/1=0 (0 to 95)
 PG7 Diagnostic imaging for embolus/thrombus +/− confirmation1/2=50 (3 to 97)
 PG8 Complication of procedure or treatment17/23=74 (51 to 89)
 PG9 Transfer to higher level of care3/22=14 (4 to 36)
 PG10 Hypoxia O2 saturation <85%0/25=0 (0 to 17)
 PG11 Cancelled elective procedure/delayed discharge1/1=100 (5 to 100)
Surgical care
 PS1 Return to theatre1/1=100 (5 to 100)
 PS2 Change in planned procedure
 PS3 Surgical site infection or hospital acquired urinary tract infection6/6=100 (52 to 100)
 PS4 Removal/injury/repair of organ
Intensive care
 IP1 Readmission to intensive care or high-dependency care
 PM1 Vitamin K (except for routine dose in neonates)
 PM2 Naloxone
 PM3 Flumazenil (romazicon)
 PM4 Glucagon or glucose ≥10%
 PM5 Chlorphenamine or antihistamine0/1=0 (0 to 95)
 PM6 Antiemetics
 PM7 IV Bolus ≥10 mL/kg colloid or crystalloid given3/19=16 (4 to 40)
 PM8 Abrupt medication stop
Lab test
 PL15 Thrombocytopenia (platelets <100)0/7=0 (0 to 44)
 PL1 High INR >5 or a PTT >100
 PL2 Transfusion2/8=25 (4 to 64)
 PL3 Abrupt drop in Hb or Hct (>25%)2/8=25 (4 to 64)
 PL4 Rising urea or creatinine (>2× baseline)0/1=0 (0 to 95)
 PL5/PL6 Electrolyte abnormalities (Na+ <130 or >150, K+ <3.0 or >6.0)0/12=0 (0 to 30)
 PL7 Hypoglycaemia (<3 mmol/L)3/8=38 (10 to 74)
 PL8 Hyperglycaemia (>12 mmol/L)0/1=0 (0 to 95)
 PL9 Drug level out of range
 PL10 MRSA bacteraemia
 PL11 Clostridium difficile
 PL13 Nosocomial pneumonia2/2=100 (20 to 100)
 PL14 Positive blood culture1/1=100 (5 to 100)
 PO1 Other event
  • The numerator represents number of harm events and the denominator how many times each individual trigger was found in all patient contacts (n=761).

  • Hb, haemoglobin; HCT, haematocrit; INR, international normalised ratio; MRSA, methicillin-resistant Staphylococcus aureus; PPV, positive predictive value; VRE, vanc resistant enterococcus.