Building Safer Systems through Critical Occurrence Reviews: Nine Years of Learning
Bibliographic record
Abstract
At The Hospital for Sick Children (SickKids), the term critical occurrence was developed to describe any event that results in an actual or potential serious, undesirable and unexpected patient or staff outcome including death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition. It also includes a breach of legislation including the Personal Health Information Protection Act of Ontario. Although broader in its definition, the term aligns closely with critical incident as defined within the amendments to Regulation 965, under the Public Hospitals Act (Government of Ontario 1990). Critical occurrences may include (but are not limited to) potential or actual adverse outcomes (including death) associated with or resulting from medication errors; a wrong site, patient or procedure performed; contaminated drugs, devices or products; an equipment malfunction; an outbreak or unusual pattern/type of nosocomial infection; employee actual or potentially serious injuries.
Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.
How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.045 | 0.084 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.003 | 0.002 |
| Science and technology studies | 0.003 | 0.007 |
| Scholarly communication | 0.012 | 0.019 |
| Open science | 0.003 | 0.006 |
| Research integrity | 0.005 | 0.008 |
| Insufficient payload (model declined to judge) | 0.007 | 0.003 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".