["111 / Clinical Service Desk call audit - Errors identified", "ABO incompatible organ transplanted", "Absent/malfunctioning thermometer (fridge and medication storage room)", "Access keypad code revealed to third party", "Access restricted / obstruction of vehicles", "Access to admission delayed", "Access to admission denied", "Access to services delayed", "Access to services denied", "Accidental breakage of phial", "Accidental damage / loss", "Accidental damage to property", "Accidental decannulation by staff", "Accidental extubation by staff", "Accidental or unintended exposure to ionising radiation", "Accidental or unintended exposure to radiation", "Actual", "Actual self-harm / self-injurious behaviour", "Acute back pain", "Acute services", "Additional procedure undertaken without consent", "Address Gazeteer issue", "Administration of contraindicated medicine", "Adult", "Adult (not known to mental health services)", "Adult known to learning disability services", "Advanced Medical Priority Dispatch System (AMPDS) Issues - AMPDS diagnostic tools", "Advanced Medical Priority Dispatch System (AMPDS) Issues - Duplicate call policy", "Advanced Medical Priority Dispatch System (AMPDS) Issues - Incorrect determinant coding", "Adverse / Allergic Reaction", "Adverse media publication", "Adverse reaction / event", "Adverse reaction to", "Adverse reaction to procedure", "Advice not given", "Advice not timely", "Airwave problems / failure", "Alarm unserviceable/ not working", "Alerts / notification / escalation failure", "All renal dialysis-related bacteraemia", "Allergic reaction (not blood products)", "Allergy to environmental substance", "Allergy to food", "Allocation delay", "Anaesthetic complications", "Animal bite/attack", "Anti social behaviour / noise nuisance", "Apgar score <7 at 5 mins", "Appointment cancelled due to demand", "Appointment errors", "Appropriate interpreter - not available / not provided", "Aseptic non-touch technique procedure not followed", "Assisted to floor", "Attempted", "attempted", "Availability", "Availability / lack of PPE (personal protective equipment)", "Baby hypo/hyper glycaemic", "Baby unexpected admission to neonatal unit (gestation up to 36 weeks)", "Bed mobility patient", "Being given adequate time to consider all of the relevant information", "Bending +/or twisting", "Birth trauma", "Bogus staff member", "Booking process (pre-treatment and treatment)", "Brachytherapy", "Breach of Integrity of PPE (including faulty PPE)", "Breach of mixed-sex accommodation guidelines", "Breach of the Mental Health Act - Documentation issues", "Break in / burglary", "Break in / burglary attempted", "Breakdown of chain of evidence", "Building alarm activated", "By a member of the public/visitor", "By a patient/service user", "Call closed in error", "Call downgraded incorrectly", "Call handling - Call not directed appropriately by call-taker/closed in error", "Call handling - Delayed response from EMS Clinical Desk/DCM", "Call left open in error", "Care delivered to wrong patient", "Care not as directed", "Carrying/supporting a load", "Chemical restraint event - Care planned", "Chemical restraint event - Not care planned", "Child known to learning disability services", "Child/adolescent (not known to mental health services)", "Choking (non-dysphagia)", "Choking (patient/service user has dysphagia)", "Chronic back pain", "Clinic cancelled / overbooked", "Clinic overrun / overbooked", "Clinical assessment documentation not completed / missing / inadequate - Patient/service user refusal", "Clinical Contact Centre (CCC) mapping systems", "Clinical details illegible/incomplete", "Clinical Response Model - Level incorrect", "Clinical triage software issues", "Closed episode of mental health care (adult)", "Closed episode of mental health care (child/adolescent)", "Coercion and other forms of social and psychological restraint", "Cold calling or nuisance emails", "Communication failure regarding infection control status", "Communication failure with another care setting", "Communication issue with patient/service user", "Communication Issues between agency / multiagency", "Communication issues between NHS bodies", "Communication issues with relative/carers", "Communication issues within unit/ward/teams", "Communication of intent", "Community acquired (established during investigation)", "Complications/query following smear", "Computer Aided Dispatch (CAD) issues", "Congenital anomaly", "Consent by a clinician who was not competent in the procedure", "Consent obtained under duress", "Consent taken after the procedure had started", "Consider or document what is in the patient/service user’s best interests correctly where the patient/service user is assessed as lacking capacity to make the decision in question", "Construction related incident", "Consult with those who care for / have an interest in the patient/service user’s welfare when making a best interests decision", "Contact with cold surface/liquid", "Contact with equipment", "Contact with hot liquid/gas", "Contact with hot surface/equipment/instrument", "Contact with mains power", "Contraindication – allergy", "Contraindication - clinical condition", "Contraindication - drug interactions", "Conveying vehicle unavailable / delayed", "Cord PH <7.05 arterial or <7.1 venous", "Cord prolapse", "Cross-matching error", "CSW Interval Cancer", "Cutlery not available", "Cutlery or crockery", "Damage - Deliberate damage to property by patient", "Damage caused whilst manoeuvring in garage", "Damage to NHS property by vehicle", "Damage to property", "Damage to vehicle", "Damaged Packaging", "Data corruption", "Data entry error", "Data loss", "Data transfer (receive / send)", "Decannulation by patient", "Decannulation by relative/carer", "Defective medicine administered", "Defective medicine used", "Delay - Hospital divert", "Delay - lack of resources due to demand / escalation", "Delay - Mode of transport unavailable", "Delay - receiving hospital declining access", "Delay - Scope of practice / training issue", "Delay - Staff role requested unavailable", "Delay - Unavailable equipment / medical device", "Delay - Unavailable nurse / medical escort", "Delay / cancelled - Due to demand / escalation", "Delay / difficulty in obtaining clinical information", "Delay / failure in recognising complication of treatment", "Delay due to escalation Deployment Management Plan (DMP)", "Delay in accessing 999 / 111", "Delay in accessing Emergency Department (ED) / ward", "Delay in accessing specialist unit / ward", "Delay in assessing and recognising patient deterioration", "Delay in clinical assessment", "Delay in collection of deceased person", "Delay in diagnosis of infection", "Delay in environmental cleaning", "Delay in FIT test", "Delay in identifying receiving hospital", "Delay in medication supply", "Delay in obtaining clinical assistance", "Delay in obtaining patient healthcare record", "Delay in prescribing", "Delay in referral in the patient pathway", "Delay in requesting clinical assistance (escalation)", "Delay in response to request for clinical assistance", "Delay in sterilisation/decontamination", "Delay in testing/processing (non-critical)", "Delay in transfusion / administration", "Delay- Lack of resources to undertake discharge", "Delay receiving results", "Delay to refer", "Delayed administration", "Delayed admission - Deteriorating patient", "Delayed specimen transport (non-critical)", "Delivery of baby born below 10th centile", "Delivery of baby with no professional in attendance (e.g. Born before admission (BBA))", "Demographic mismatch", "Denial of access", "Denial of Service", "Denied - Access to specialist Unit / ward", "Denied - Hospital divert", "Denied - Request for clinical assistance", "Denied by Emergency Department (ED) - Deteriorating patient", "Denied by Emergency Department (ED) / ward", "Denied by minor injuries unit or community services", "Denied due to escalation (Deployment Management Plan (DMP))", "Deployment Issues - Difficulty in Accessing Location/Address", "Deployment Issues - Frequent caller", "Deployment Issues - Inappropriate deployment", "Deployment Issues - Inappropriate use of Emergency Medical Services (EMS) services", "Deployment Issues - No / lack of available resources to allocate", "Deployment Issues - Scene safety issue", "Deprivation of liberty due to clinical assessment", "Deprivation of liberty due to documentation", "Destruction", "Device instructions unavailable", "Device-related mucosal pressure ulcer", "Device-related pressure ulcer category 1", "Device-related pressure ulcer category 2", "Device-related pressure ulcer category 3", "Device-related pressure ulcer category 4", "Device-related suspected deep tissue injury", "Device-related unstageable pressure ulcer", "Diagnosis delayed", "Diagnosis issues", "Diagnosis wrong (mis-diagnosis)", "Diet not supplied.", "Difficulty in accessing address / location", "Discharge - wrong patient conveyed", "Discharge delay other", "Discharge delayed", "Discharge inappropriate", "Discharge long waiting / journey time", "Discharge planning failure - Medical devices (including equipment, dressings, continence aids) not provided on discharge", "Discharge planning failure - Medication not prepared", "Discharge planning failure - No home support", "Discharge planning failure - Referred services did not attend", "Discharge planning failure - Service referral not made", "Discharged - to wrong location / address", "Discharged with cannula insitu", "Disconnection leading to haemorrhage at any part of the dialysis circuit resulting in blood loss that requires further management", "Document management", "Documentation Error", "Documentation missing", "Documents misfiled in healthcare record (wrong patient)", "Documents not available", "Donor consent / documentation issue", "Drinking alcohol on NHS premises", "Driving related issues", "Drug content errors - Expired medication", "Drug content errors - Incorrect form", "Drug content errors - Incorrect medication", "Drug content errors - Incorrect patient/service user information leaflet", "Drug content errors - Incorrect quantity", "Drug content errors - Incorrect strength", "Drug content errors - Omitted patient/service user information leaflet", "Drug paraphernalia found", "Drug storage of controlled drugs on vehicle", "Drug storage Omnicell cabinets issue", "Duplication of medication", "During clinical application - clean/unused", "During clinical application - contaminated/used", "During clinical application - Resheathing clean/unused", "During clinical application - Resheathing contaminated/used", "During disposal - No safety fitting on sharp clean/unused", "During disposal - No safety fitting on sharp contaminated/used", "During disposal - Safety fitting not deployed clean/unused", "During disposal - Safety fitting not deployed contaminated/used", "During disposal - Whilst deploying safety fitting clean/unused", "During disposal - Whilst deploying safety fitting contaminated/used", "During preparation - clean/unused", "During preparation - contaminated/used", "During preparation - Resheathing clean/unused", "During preparation - Resheathing contaminated/used", "Early administration", "End of treatment process", "Endocervical brush not used", "Endocervical brush only used", "Engaging in threatening behaviour in large groups", "Enteral feeding tubes (NG, PEG, RIG, Jej Tube incidents – placement, usage, documentation etc)", "Entrapment (not in bedrails)", "Entrapment in bedrails", "Entrapped in a lift/elevator", "Entrapped in a room (including toilet)", "Entrapped in equipment/machinery", "Environmental Cause - (Noise, Temperature etc.)", "Environmental restraint event - Care planned", "Environmental restraint event - Not care planned", "Equipment or machinery", "Equipment use error", "Error - mistaken patient identity", "Exceptional infection episode", "Expired equipment/device", "Expired medication/diluent used", "Expired medication/fluid", "Exposed to Asbestos", "Exposed to blood or bodily fluids (not needlestick or sharps injury)", "Exposed to chemical substance", "Exposure to dust, gas or fumes", "Exposure to propagated culture", "Exposure to smoke or fire", "Exposure to vermin and animal faeces", "Extended stay / episode of care", "External", "Extravasation (infusion injury)", "Extubation by patient", "Extubation by relative/carer", "Failure / delay to interpret or act on an infection test result / report", "Failure / delay to receive an infection test result / report", "Failure / error in automated process", "Failure batch printing", "Failure in patient alarm system", "Failure in referral process", "Failure in sterilisation/decontamination", "Failure of back up generator", "Failure of digital process - clinical (referral / Follow up)", "Failure of equipment", "Failure of heating", "Failure of lighting", "Failure of medical device", "Failure of power or energy source", "Failure of protected mealtimes", "Failure of service specific systems", "Failure of water", "Failure scanning process", "Failure to act", "Failure to adhere to equality and diversity policy/guidelines", "Failure to assess need for, or supply/obtain modified cutlery.", "Failure to assess patient/service user for aids/support to eat or drink", "Failure to assess swallow / failure to refer or late referral to Speech and Language Therapy", "Failure to attend dialysis due to reduced dialysis capacity", "Failure to attend dialysis due to transport failure", "Failure to clinically assess", "Failure to clinically assess or inadequate clinical assessment - Patient/service user clinically challenging behaviour", "Failure to collect or deliver items", "Failure to complete and document patient observations", "Failure to complete assessment on admission.", "Failure to complete assessments", "Failure to comply with blood transfusion procedure/documentation/cold chain", "Failure to diagnose (missed diagnosis)", "Failure to diagnose infection", "Failure to discontinue treatment", "Failure to dispose of clinical waste appropriately (excluding sharps)", "Failure to dispose of domestic waste appropriately", "Failure to ensure patients ready for meals", "Failure to ensure privacy and dignity for the patient", "Failure to follow correct process or procedure for environmental cleaning", "Failure to follow protocol/SOP", "Failure to follow Safeguarding policies / procedures", "Failure to follow up a missed appointment by a patient/service user", "Failure to handle concerns adequately", "Failure to install functional collapsible shower or curtain rails", "Failure to maintain appropriate noise / vibration levels", "Failure to maintain temperature at appropriate levels", "Failure to monitor fluid balance adequately", "Failure to monitor patient adequately", "Failure to monitor patient/service user adequately", "Failure to process technical (saving / retrieving)", "Failure to provide adequate hydration", "Failure to provide appropriate special diet", "Failure to provide patient/service user with assistance to eat or drink", "Failure to refer", "Failure to request another appointment", "Failure to resource service adequately", "Failure to return from authorised leave", "Failure to save information (e.g. digital dictation)", "Failure to undertake appropriate monitoring", "Faint/collapse", "Fall downstairs", "Fall from bed/trolley", "Fall from chair", "Fall from commode", "Fall from height", "Fall from poorly restricted windows", "Fall on a slippery or wet surface", "Fall on level surface (external)", "Fall on level surface (internal)", "Fall on sloping surface (external)", "Fall on sloping surface (internal)", "Fall on stairs", "Fall on uneven ground", "Fall upstairs", "Fall using bathroom/toilet", "Fall with resulting entrapment (not bedrails)", "Fall/slip from chair, bed or trolley", "Falsified entry", "Falsified signature", "Fetal laceration at caesarean section", "Fire", "Fire alarm activation - unwanted fire signal (UwFS)", "Fire door left open/inappropriate use", "FIT test failure", "Fixtures and fittings", "Flood / leaks", "Follow a valid and applicable Advance Decision to Refuse Treatment (ADRT)", "Follow-up process", "Forged documentation", "Forged identification", "Found on the floor", "Fridge / freezer issue – compromised relevant material", "Fridge / freezer issue – loss of relevant material", "Fridge / freezer issue – no loss of relevant material", "From height", "General radio problem/failure", "Gillick competent child / young person not given the opportunity to consent for themselves", "Give the patient/service user the opportunity to request further information or clarification on the examination or treatment", "Glass/sharp object (not medical sharp or needlestick)", "Haemorrhage", "Hand held radio issue/problem/failure", "Hand hygiene standards compliance", "Healthcare associated - actual", "Healthcare associated - indeterminate", "Healthcare associated - probable", "Healthcare professional registration expired", "Healthcare record not available", "Hoisting patient", "Home dialysis water failure resulting in reduced or change in modality", "Hospital acquired deep vein thrombosis (DVT)", "Hospital acquired pulmonary embolism (PE)", "HTA documentation lost or incorrect", "Hysterectomy/laparotomy", "Identification wristbands not on patient (adult)", "Identification wristbands not on patient (infant/child)", "Ilfiltration/Interception - Virus hacking", "Illegal prescription", "Illegible entry in healthcare record", "Images - missing", "Images - not available when required", "Images not available", "Images not saved", "Impacted Fetal Head", "In furniture/fixtures/fittings/equipment/machinery", "Inability to retrieve information e.g. Subject access request", "Inaccurately completed medicines administration documentation", "Inadequate clinical assessment", "Inadequate handover of care", "Inadequate levels of supplies maintained", "Inadequate pain relief", "Inadequate PPE (including fit/quality/staff overheating)", "Inadequate/inaccurate unique identifiers", "Inappropriate access e.g. leavers", "Inappropriate behaviour / attitude", "Inappropriate cold chain transport", "Inappropriate collection, use or storage of relevant material", "Inappropriate destruction of corporate records", "Inappropriate destruction of patient/service user health records", "Inappropriate destruction of staff records", "Inappropriate disposal - Other", "Inappropriate disposal - Sharp found at bed side", "Inappropriate disposal - Sharp found in waste", "Inappropriate disposal - Sharp returned to the hospital sterilising and disinfection unit (HSDU)", "Inappropriate location for Parenteral Nutrition administration", "Inappropriate medication storage facility", "Inappropriate method of disposal/denaturing", "Inappropriate patient pathway", "Inappropriate record retention/destruction", "Inappropriate request for test/treatment/procedure", "Inappropriate response/action", "Inappropriate sexual behaviour to member of the public", "Inappropriate sexual behaviour to patient/service user", "Inappropriate sexual behaviour to staff", "Inappropriate storage of specimen", "Inappropriate test request form used", "Inappropriate test/treatment /procedure carried out", "Inappropriate use of organisation systems", "Inappropriately outlying of patient(s) (not clinically indicated)", "Inappropriately outlying of patient(s) (not clinically indicated)", "Inappropriately stored medicine used", "Inappropriately stored medicine/diluent used", "Incompatible syringe/container used", "Incomplete information received / sent", "Incomplete medicines administration documentation", "Incorrect", "Incorrect administration technique", "Incorrect advice", "Incorrect blood/plasma/product transfused", "Incorrect decannulation by staff", "Incorrect device", "Incorrect donning/doffing procedure", "Incorrect dose administered", "Incorrect dose/change to dose", "Incorrect duration of treatment", "Incorrect extubation by staff", "Incorrect food hygiene practices", "Incorrect food hygiene procedures", "Incorrect form of medication/diluent used", "Incorrect formulation", "Incorrect Infection diagnosis", "Incorrect infection test result / report", "Incorrect information documented", "Incorrect labelling of deceased", "Incorrect lock", "Incorrect measurements entered on Daybook/ paper copies", "Incorrect medical gases given", "Incorrect medication/diluent", "Incorrect medication/fluid", "Incorrect method of preparation", "Incorrect patient/service user", "Incorrect procedure for handling of bodily fluids / tissue followed", "Incorrect procedure for isolation immunocompromised patient followed", "Incorrect procedure for isolation of infected patients followed", "Incorrect process or procedure for environmental cleaning followed", "Incorrect quantity/running balance", "Incorrect quantity/volume of medication/diluent used", "Incorrect rate of administration", "Incorrect referral classification", "Incorrect removal of central line by staff", "Incorrect removal of wound drain", "Incorrect result reported", "Incorrect route", "Incorrect Sample Taker Code", "Incorrect service user selected on ultrasound machine", "Incorrect sterilisation/decontamination process", "Incorrect strength/diluent medication", "Incorrect strength/dose", "Incorrect volume of feed administered", "Incorrect/incomplete collector details", "Incorrect/omitted authority to possess", "Incorrect/omitted date", "Incorrect/omitted drug details", "Incorrect/omitted drug details on label", "Incorrect/omitted frequency", "Incorrect/omitted patient/service user/ward/clinical area supplied", "Incorrect/omitted route of administration", "Incorrect/omitted supplier details", "Incorrect/omitted timing of dose", "Infant/child", "Infection outbreak", "Infestation", "Infiltration", "Inform the patient/service user’s family of a DoLS / LPS application / referral", "Information missing", "Information not available in the appropriate language / format (outside of the consent process)", "Information not recorded in the health record", "Information presented / displayed incorrectly", "Information printed incorrectly", "Injured during a manual handling manoeuvre", "Injured whilst being moved with manual handling equipment", "Injury of unknown origin / unwitnessed", "Injury to patient when handling or positioning", "Insect/pest bite", "Instruct and consult with an Independent Mental Capacity Advocate (IMCA) where required under the MCA / MC(A)A", "Insufficient fluid / sample", "Insufficient/incomplete advice ", "Intended benefits not discussed", "Internal", "Internal", "Intruder", "Intrusion", "In-vehicle satellite navigation system", "Involving ambulance (patient on board)", "Inward journey/waiting time", "Issue errors - Ancillaries not supplied when necessary", "Issue errors - Inappropriately stored mediation supplied", "Issue errors - Medication not delivered", "Issue errors - Medication not supplied against prescription/order", "Issue errors - Medication supplied that was not prescribed", "Issue errors - Supplied to wrong patient/ward", "Issue errors - Supply against illegal prescription", "Issue errors - Supply of a defective product", "Issues with Parenteral Nutrition bag", "IT equipment/organisation policy", "Labelling errors - Incorrect directions", "Labelling errors - Incorrect form", "Labelling errors - Incorrect medication", "Labelling errors - Incorrect strength", "Labelling errors - Incorrect/incomplete patient/service user name", "Labelling errors - Incorrect/omitted expiry date", "Labelling errors - Incorrect/omitted warnings/cautionary labels", "Labelling errors - Omitted directions", "Labelling errors - Omitted patient/service user name", "Laboratory technical error/ mishandled samples", "Lack of appropriate supervision to staff", "Lack of availability of beds", "Lack of availability of beds (high dependency)", "Lack of availability of equipment", "Lack of availability of equipment consumables", "Lack of availability of medical device", "Lack of availability of medical device consumables", "Lack of availability of nutritional products", "Lack of clarity over correct equipment/PPE", "Lack of documentation of the patient/service user’s decision", "Lack of operating theatre", "Lack of suitably trained staff", "Late delivery of meal trolley", "Late for appointment", "Late for appointment - Out of area", "Length of time on vehicle", "Lifting/lowering a load", "Long term segregation - Care planned", "Long term segregation - Not care planned", "Loss of information - electronic", "Lost access keys", "Lost or delayed laboratory specimens during transportation", "Lost/misplaced keys", "Lost/misplaced medicines", "Lost/misplaced records", "Lower limb pain/disorder", "Magnetic resonance imaging (MRI) errors", "Maintainence: Damp / humid", "Maintenance - Building", "Maintenance - Electrical", "Maintenance - Heating", "Maintenance - Mechanical", "Maintenance - Poor lighting", "Major post-partum haemorrhage (> 1500mls)", "Make an application / referral under the DoLS / LPS scheme", "Malicious code", "Management of the falling patient", "Manual handling aid / equipment required but unavailable", "Maternal death", "Mechanical restraint event - Care planned", "Mechanical restraint event - Not care planned", "Medical device user error", "Medical History not disclosed by donor", "Medical Priority Dispatch System (MPDS) - Call audit errors identified", "Medical Priority Dispatch System (MPDS) - Delay - Location / address incorrect", "Medical Priority Dispatch System (MPDS) - Incorrect determinant coding", "Medical Priority Dispatch System (MPDS) - Pre-arrival instructions incorrect / not provided", "Medical Priority Dispatch System (MPDS) - Utilisation of diagnostic tools", "Medication delivery to an unsecure area", "Medication left unattended", "Medication not segregated appropriately", "Medication not taken by patient/service user as prescribed", "Medication storage temperature out of range", "Member of public to patient/service user", "Member of the public to member of the public", "Member of the public to staff", "Mental Health & Learning Disability Services", "Misappropriation", "Mislabelled healthcare record", "Misleading advice", "Mismatch between patient and request form", "Misplaced naso- or oro-gastric tube", "Missed appointment - Transport issues", "Missing / incorrect / incomplete / illegible: No record / evidence of patient/service user information being given to the patient/service user in relation to the examination or treatment including patient/service user/service user information leaflet", "Missing / incorrect / incomplete / illegible: Form completed incorrectly / missing information", "Missing / incorrect / incomplete / illegible: Illegible / inadequate record of the information given to the patient/service user", "Missing / incorrect / incomplete / illegible: Incorrect / inappropriate / out of date patient/service user information given to the patient/service in relation to the examination or treatment including patient/service user information leaflet", "Missing / incorrect / incomplete / illegible: Incorrect / out of date consent form used: Form completed incorrectly / missing information", "Missing / incorrect / incomplete / illegible: patient/service user Information leaflet not offered / unavailable in the language of choice", "Missing / incorrect / incomplete / illegible: Record missing – lost / damaged / stolen / incomplete", "Missing healthcare record", "Missing infection test result / report", "Missing needle/swab/instrument/string/pack", "Missing patient/service user", "Missing referral letter (did not arrive)", "Missing/unavailable", "Mistaken patient identity", "Mix up of records", "Mobile data terminal issue", "Moisture-associated skin damage (MASD) (incontinence-associated)", "Moisture-associated skin damage (MASD) (not incontinence-associated)", "Mould room/workshop activities", "Muscle pain", "Neonatal death", "Neonatal seizures", "New equipment", "NHS owned/contract vehicle not adequately maintained/road worthy", "NICE recorder issues", "Nil By Mouth (NBM) issues – prolonged NBM, Cancelled operations etc.", "Nil by mouth for excessive period", "No / inadequate record of the consent process in the patient/service user's record where a consent form is not required / used", "No / incorrect patient/service user details selected", "No access to radio communications", "No escort on admission / attendance", "No label on prepared medication", "No sample taker code on HMR form", "Non compliance with bundle/guidance", "Non conveyance to healthcare facility following treatment", "Not made (lost to follow up)", "Obtain consent from an Attorney appointed under a Lasting Power of Attorney (LPA) for Health and Welfare or a Court Appointed Deputy where they have authority to consent for the patient/service user", "Obtain Court authorisation when required / appropriate", "Occupational Dermatitis", "Omission of temperature monitoring (fridge and medication storage room)", "Omitted dose of medication", "Omitted entry for receipt/supply/collection/delivery", "Omitted medication", "Omitted medicine", "Omitted second check of administration", "Omitted second check of preparation", "Oncology transport issues", "Ongoing care - Mode of conveyance chosen", "On-treatment review process", "Open episode of mental health care (adult)", "Open episode of mental health care (child/adolescent)", "Ordered meal incomplete", "Organisation data held or stored", "Other", "Other HTA issue (Including research)", "Other maternal adverse occurrence", "Other maternity adverse occurrence", "Other neonatal adverse occurrence", "Out of date consumable used", "Outward journey/waiting time", "Overfilled sharps container", "Patient Centred Response Matrix - Poor patient outcome", "Patient escort refused transport", "Patient records/information inappropriately accessed (electronic and paper)", "Patient records/information inappropriately divulged", "Patient records/information lost (electronic and paper)", "Patient records/information sent to wrong recipient (electronic and paper)", "Patient records/information stolen (electronic and paper)", "Patient to public/visitor", "Patient with infestation", "Patient/service user allergy to equipment used during preparation", "Patient/service user exposed to domestic abuse", "Patient/service user exposed to emotional abuse", "Patient/service user exposed to financial abuse", "Patient/service user exposed to financial assault", "Patient/service user incorrectly identified", "Patient/service user not consented for the examination or treatment", "Patient/service user protest", "Patient/service user self neglect", "Patient/service user to member of the public", "Patient/service user to patient/service user", "Patient/service user to patient/service user", "Patient/service user to patient/service user harassment", "Patient/service user to patient/service user physical assault", "Patient/service user to patient/service user racial abuse", "Patient/service user to patient/service user sexual abuse", "Patient/service user to patient/service user verbal abuse", "Patient/service user to staff", "Patient/service user/service user to patient/service user/service user", "Patients dehydrated or over-hydrated due to poor or incomplete Fluid Balance Charts", "Period of increased incidence", "Permcath / temporary catheter failures (blocked, split, fall out) resulting in reduced /delayed treatment time and the use temporary vascular access", "Physical assault to member of the public", "Physical assault to patient/service user", "Physical assault to staff", "Physical restraint event - Care planned", "Physical restraint event - Not care planned", "Place of work", "Planned", "Poor general cleaning practices", "Poor Nutritional Transfer – without feed, pumps, equipment etc.", "Poor Site/Traffic Management", "Poorly maintained device", "Post-partum haemorrhage (1000mls - 1499mls)", "Postponement / delay of induction of labour or elective procedure", "Pre transfusion laboratory testing", "Pre-eclampsia / eclampsia", "Prescription sheet incorrectly completed or not signed", "Prescription sheet missing", "Prescriptions", "Pressure damage", "Pressure ulcer category 1", "Pressure ulcer category 2", "Pressure ulcer category 3", "Pressure ulcer category 4", "Pre-transfusion ordering", "Pre-treatment activities / imaging (to include CT, simulation, clinical mark-up)", "Pre-treatment planning process", "Pre-treatment: preparation of patient", "Printer / fax issues", "Procedure abandoned", "Processes prior to first appointment", "Property/money of deceased not secured", "Public or relative / carer to patient/service user bullying and harassment", "Public or relative / carer to patient/service user harassment", "Public or relative / carer to patient/service user neglect", "Public or relative / carer to patient/service user physical assault", "Public or relative / carer to patient/service user racial abuse", "Public or relative / carer to patient/service user sexual abuse", "Public or relative / carer to patient/service user verbal abuse", "Public protest", "Pushing/pulling a load", "Radiation safety practitioner errors", "Radio headsets failure", "Radiology contrast errors", "Reaching +/or stretching", "Reasonable alternative treatment options not discussed", "Recording of staff on patients devices", "Referral destination incorrect", "Referral errors", "Referral for treatment", "Referral incorrect / not completed", "Referral issues / problems", "Referral not made", "Removal of central line by patient", "Removal of central line by relative/carer", "Removal of wound drain by patient", "Renal dialysis-related bacteraemia due to inadequate vascular access service provision", "Repetitive vehicle defect", "Reporting errors", "Reports - failure/delay to receive", "Reports - missing", "Request form - incomplete", "Request form - incorrect patient information details", "Required records not maintained", "Requirement for PPE not supported", "Restricted access to premises", "Resuscitation delay", "Resuscitation event (care as appropriate)", "Resuscitation event (care aspect failure)", "Retained needle/swab/instrument/string/pack", "Reverse osmosis failure resulting in reduced or change in modality treatment", "Risks – including material risks to this patient/service user not discussed", "Risks resulting from the patient/service user’s decision not explained to the patient/service user", "Road traffic collision NHS Site", "Road traffic collision private land", "Road traffic collision public highway", "Room design", "Routine Machine QA", "Ruptured bladder", "Safeguarding - Other", "Safety errors related to radioisotopes [not IR(ME)R] and Ionising Radiation Regulations 17", "Sample lost", "Sample mix up", "Sample mix-up (found before result entry)", "Sample/fluid overfilled", "Sampler head present in vial", "Satellite Navigation system issues", "Scientific infrastructure", "Screened Inappropriately - Hysterectomy", "Screened Inappropriately - Outside age parameters", "Screened Inappropriately - Vault sample taken in primary care", "Screened inappropriately (own org responsibility)", "Screening not complete - Cervix not seen", "Seclusion or enforced isolation - Care planned", "Seclusion or enforced isolation - Not care planned", "Security door left open/inappropriate use", "Self-care advice - Incorrect / not provided", "Self-discharge against medical advice", "Server overload/failure/problem", "Shoulder dystocia", "Sitting/standing/walking patient", "Skin Damage", "Smear repeated too soon", "Smear repeated too soon, within 12 weeks of previous test", "Smear repeated too soon, post-natal/ termination/ miscarriage", "Smoking on NHS premises", "Specimen discarded in error", "Specimen inadequate", "Specimen leaking", "Specimen mislabelled or unlabelled", "Specimen missing", "Spillage", "Spillage of known hazardous substance", "Spillage of unknown hazardous substance", "Staff attitude to patient/service user, visitor, public", "Staff ID badge lost", "Staff ID badge shared", "Staff injured while undertaking Restrictive Practice Interventions (RPI)", "Staff IT password shared", "Staff management", "Staff records/information inappropriately accessed (electronic and paper)", "Staff records/information inappropriately divulged", "Staff records/information lost (electronic and paper)", "Staff records/information sent to wrong recipient (electronic and paper)", "Staff records/information stolen (electronic and paper)", "Staff to member of the public", "Staff to patient/service user", "Staff to patient/service user harassment", "Staff to patient/service user neglect", "Staff to patient/service user physical assault", "Staff to patient/service user racial abuse", "Staff to staff", "Standard of driving", "Standard of food / choice (including temperature)", "Starting dialysis with a line due to inadequate clinical care or vascular access service provision", "Sterility expired", "Stillbirth", "Stolen / unauthorized access to relevant material", "Storage, location and security of equipment", "Struck against stationary object e.g. furniture, fixtures, fittings, equipment, machinery", "Struck by falling or collapsing Object", "Struck by moving object e.g. closing door, falling shelf", "Struck by moving vehicle i.e. tug, forklift", "Substance use on NHS premises", "Suspect package", "Suspected deep tissue injury", "Suspected self-harm / self-injurious behaviour", "Tablet computer / IPAD issue", "Telecommunications failure including bleeps", "Telephone problems/failure", "Test kit not issued or missing", "Test not ordered or undertaken", "Test not ordered or undertaken (excluding pathology/radiology) e.g. ECG.", "Test request form not present or incomplete", "Test result delayed", "Test results / reports - failure / delay to interpret or act on", "Test results / reports - failure / delay to interpret or act on (excluding pathology/radiology) e.g. ECG", "Test results not available", "The ability to follow the consent process in a format and language they can understand including the Welsh Language", "The presence of any trainees or students not discussed", "The requirement to take and retain tissue samples, photographs etc", "The use of any experimental techniques", "Theatre list details incorrect", "Theft from vehicle", "Theft of IT equipment", "Theft of organisation property", "Theft of patient's property/money", "Theft of staff property/money", "Theft of vehicle", "Theft/Missing/Loss of patient's property/money", "Third or fourth degree tear", "Timing", "Tissue disposal issue", "Tissue traceability issue", "Tissue transfer / transportation issue", "Toileting patient", "Traceability", "Transcription Error", "Transfer delay - other", "Transfer delayed", "Transfer failure of image/clinic details/soundwaves", "Transfer inappropriate or unsafe", "Transfer to a unit / ward in a secondary care provider", "Transfer to tertiary care", "Transfer waiting time - other", "Transferring between the bed/chair/commode ", "Transmitter failure", "Transport booking not received / incorrect details", "Transport cancelled due to demand", "Transport cancelled due to error", "Transport declined against clinical / medical advice", "Transport delayed", "Transport error - wrong address / location", "Transport error - wrong patient conveyed", "Transport inappropriate or unsafe", "Transport inappropriate/unsafe/uncomfortable", "Transport request declined due to demand / escalation", "Transport request declined due to eligibility criteria", "Treatment data entry process", "Treatment or procedure delayed", "Treatment or procedure not given as directed", "Treatment or procedure wrong or inappropriate", "Treatment unit process", "Trespasser in unauthorised area", "Triage process issue (Algorithm)", "Trip or fall over an object or obstacle", "Two Cervices", "Type of transport unsuitable / inappropriate", "Ultrasound safety errors", "Unable to access all systems", "Unable to access one system", "Unauthorised access - electronic", "Unauthorised access - paper", "Unauthorised access to medicines", "Unauthorised administration", "Unauthorised installation of hardware", "Unauthorised modifications or adjustments", "Unauthorised self-administration", "Unavailable equipment / medical device", "Undertake and / or document a capacity assessment in accordance with the requirements of the MCA", "Undiagnosed fetal abnormality", "Undiagnosed malpresentation including breech in labour", "Unexpected admission / readmission to high dependency care", "Unexpected admission / readmission to intensive care", "Unexpected admission / readmission to ward", "Unexpected admission to neonatal unit (gestation 37 weeks+)", "Unexpected re-attendance in the community", "Unexpected re-attendance to the emergency department / minor injuries", "Unintended injury during procedure", "Uninvited individual aged 24.5 years or younger", "Unlabelled processed specimen", "Unlocked medication storage room/facility", "Unnecessary non-ionising radiation investigation (Ultrasound/MRI)", "Unnecessary radiological investigation", "Unplanned", "Unplanned returned to theatre", "Unprescribed drug prepared", "Unsecure transport of medicines", "Unstageable pressure ulcer", "Unsuccessful / inappropriate use of forceps or ventouse", "Upper limb pain/disorder", "Use of NHS owned equipment and services", "Using manual handling equipment", "Uterine rupture", "Vandalism", "Vehicle breakdown whilst in service", "Vehicle design and layout", "Vehicle fire", "Vehicle heating / temperature", "Verbal assault to member of the public", "Verbal assault to patient/service user", "Verbal assault to staff", "Vial leaked in transit", "Vials or ampoules", "Virus/Worm/Trojan Infection", "Waste - avoidable", "Waste - unavoidable", "Weapons detected or confiscated", "Welsh Language Standards not met / complied with", "When not in use, medication trolleys/patient’s own locker not stored securely", "Wide area network problems/failure", "Work related stress", "Worsening advice - Incorrect / not provided", "Wound infection", "Wrong address / destination provided", "Wrong consistency", "Wrong device used", "Wrong equipment used", "Wrong feed dispensed", "Wrong feed prescribed", "Wrong fuel used", "Wrong information in record", "Wrong meal received from Kitchen", "Wrong pathway (ceased inappropriately)", "Wrong pathway (less frequent)", "Wrong pathway (not paused)", "Wrong pathway (too frequent)", "Wrong pathway assigned to service user ", "Wrong patient details presented (in full or partial)", "Wrong patient identity", "Wrong site surgery", "Wrong texture of food for patient needs", "Wrong type of vial used"]