Patient handoffs are a common source of adverse events, often due to communication failures, particularly for tests that are pending at discharge. This research group used incident reports, interviews, and root cause analysis reports to create and validate a taxonomy for classifying adverse events related to patient handovers.

Analysis of incident reports revealed common types of errors in cardiopulmonary resuscitation and identified areas for education and further training. Errors were categorized into seven areas: alerting the resuscitation team, human performance, equipment failure, resuscitation equipment not available, physical environment, insufficient monitoring, and medication error.