Table 3 Themes identified during walk rounds.*

1. Medication ordering policy not followed (handwriting illegible, cannot identify ordering MD, etc.)

2. The medicaton administration record is not always reconciled with the most recent orders

3. Active interventions not maintained on the electronic medical record

4. Need to improve discharge education for patients on anticoagulants

5. House officers need better supervision when conducting procedures and nurses need a way to identify house officer training level and which procedures are appropriate for that level.

6. Difficulties in caring for medical patients with significant psychiatric problems

7. Management of overweight patients (inadequate equipment, difficulty turning, transporting)

8. Problems with TPN orders in neonatal intensive care

9. Inconsistent application of the falls prevention program

10. Difficulties in transitioning patients from Emergency Department to intensive care units (timing of transfer, use of different intravenous drug concentrations)

11. Improper use of oxygen tanks when patients transported

12. Beds not well maintained (wheel locks malfunction, frayed electrical cords)