Post on 03-Jan-2016
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Part 1 6-Apr-2006
AIR
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Part 2 6-Apr-2006
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Part 3 6-Apr-2006
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Part 1 11-May-2006
EX
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TL
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ATP
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Part 2 11-May-2006
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Part 1 6-Apr-2006
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Part 2 6-Apr-2006
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Part 1 11-May-2006
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Part 2 11-May-2006
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Part 1 6-Apr-2006
TL
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1 30 2 30 3 3 30 4 4 30 5 5 30 6 7 7 30 8 30 9 306 30 8 9 1020
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Part 1 11-May-2006
1 30 2 30 3 3 30 4 4 30 5 5 30 6 7 7 30 8 30 9 306 30 8 9 1020
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Part 1 11-May-2006C
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Part 1 7-Nov-2006
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Part 1 6-Apr-2006
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1.a) of 6 April 2006
MEDICAL CODES
(time axis not to scale)
TL
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ATP
RT
ANST
PHRM
X-ray
ORT
Other
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PHRM
X-ray
Other
18 2
Part 2
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID
S4S5S6S7
B5
C6C7
S8
D1D2D3
18 5
4
19 1
7
20
20 3
6
21 9
21 2
9
20 1
1
21 4
9
22 1
1
22 2
4
22 5
4
24 4
2
TL
JR
PNR
REC
CCT
ATP
RT
ANST
SR
X-ray
Other
23 5
6
18 4
4
?
25 8
Part 3
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID
S4S5S6S7
B5
C6C7
S8
D1D2D3
?
V
1 4
7
B2
A1
1 5
8
C2
2 2
0
C3
2 4
1E3
ORT
B?
3 1
13
16
S3
C1
3 3
2
CIR
C4C5
Bwl
B1
B3B4
A2A3A4
E2E1
S2S1
MIID
TL
JR
PNR
REC
CCT
ATP
RT
EMS
Other
X-ray
S4S5S6
PTN
4 2
4
F
5 9
5 3
5
5 5
3
6 5
7
7 2
8
S7
7 4
5
8 2
7
8 5
9
0Part 1
14 4
4
V
B2
A1
10 1
C2
10 3
2
C3
10 4
7E3
ORT
B?
11 2
7
10 5
2
S3
C1
12 2
CIR
C4C5
D2
B1
B3B4
A2A3A4
E2E1
S2S1
MI
ID
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
S4S5S6
PTN
12 4
8
F
13 3
313
50
15 3
2
16 2
6
16 4
8
S7
17 9
17 3
8
18 4
4
8 5
9
15 5
4
M
Other
18 2
Part 2
V
B2
A1
18 5
4
C2
19 1
7
C3
E3
ORT
B?
20
S3
C1
20 3
6
CIR
C4C5
D2
B1
B3B4
A2A3A4
E2E1
S2S1
MI
ID
S4S5S6
PTN
21 9
F
21 2
9
20 1
1
21 4
1
22 1
1
S7
22 2
4
22 5
4
24 4
2
M
TL
JR
PNR
REC
CCT
ATP
RT
ANST
SR
X-ray
Other
23 5
6
18 4
4
? ??
?
?
??
?
?
?
25 8
Part 3
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Count of lines an actor appears in transcript of Event #3, per minute (values range: 0 – 15)Endotracheal intubation
Primary survey
Accident reporting
Instrumentation setup
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Count of lines an actor appears in transcript of Event #3, per minute (values range: 0 – 15)
Primary survey
Accident reporting
Instrumentation setup
Endotracheal intubation
Temporal occurrence of errors - Randy
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Count of lines an actor appears in transcript of Event #3, per minute (values range: 0 – 15)
Endotracheal intubation
Primary survey
Accident reporting
Instrumentation setup
Omission errorsCommission errorsSelection errors
Temporal occurrence of errors - Meredith
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Count of lines an actor appears in transcript of Event #3, per minute (values range: 0 – 15)
Endotracheal intubation
Primary survey
Accident reporting
Instrumentation setup
Other:
Omission errorsCommission errorsSelection errors
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Primary survey
Instrumentation setup
Endotracheal intubation
Incident reporting
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Primary survey
Instrumentation setup
Endotracheal intubation
Incident reporting Error of omissionError of commissionError of selectionCommunication error
16.67
Omission errorsCommission errorsSelection errorsCommunication errors
CCT
TL
PNR
JR
REC
ANES
ATP
Other