Near misses and unsafe conditions reported in a Pediatric Emergency Research Network

BMJ Open
Richard M RuddyPediatric Emergency Care Applied Research Network

Abstract

Patient safety may be enhanced by using reports from front-line staff of near misses and unsafe conditions to identify latent safety events. We describe paediatric emergency department (ED) near-miss events and unsafe conditions from hospital reporting systems in a 1-year observational study from hospitals participating in the Pediatric Emergency Care Applied Research Network (PECARN). This is a secondary analysis of 1 year of incident reports (IRs) from 18 EDs in 2007-2008. Using a prior taxonomy and established method, this analysis is of all reports classified as near-miss (events not reaching the patient) or unsafe condition. Classification included type, severity, contributing factors and personnel involved. In-depth review of 20% of IRs was performed. 487 reports (16.8% of eligible IRs) are included. Most common were medication-related, followed by laboratory-related, radiology-related and process-related IRs. Human factors issues were related to 87% and equipment issues to 11%. Human factor issues related to non-compliance with procedures accounted for 66.4%, including 5.95% with no or incorrect ID. Handoff issues were important in 11.5%. Medication and process-related issues are important causes of near miss and unsafe ...Continue Reading

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Mar 29, 2016·Pediatric Clinics of North America·Brian S Martin, Mark Arbore
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