Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care (original) (raw)
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Anatomy of a patient safety event: a pediatric patient safety taxonomy
2005
Background: Idiosyncratic terminology and frameworks in the study of patient safety have been tolerated but are increasingly problematic. Agreement on standard language and frameworks is needed for optimal improvement and dissemination of knowledge about patient safety. Methods: Patient safety events were assessed using critical incident analysis, a method used to classify risks that has been more recently applied to medicine. Clinician interviews and clinician reports to a web based reporting system were used for analysis of hospital based and ambulatory care events, respectively. Events were classified independently by three investigators. Results: A pediatric patient safety taxonomy, relevant to both hospital based and ambulatory pediatric care, was developed from the analysis of 122 hospital based and 144 ambulatory care events. It is composed of four main categories: (1) problem type; (2) domain of medicine; (3) contributing factors in the patient (child-specific), environment (latent conditions) and care providers (human factors); and (4) outcome or result of the event and level of harm. A classification of preventive mechanisms was also developed. Inter-rater reliability of classifications ranged from 72% to 86% for sub-categories of the taxonomy. Conclusions: This patient safety taxonomy reflects the nature of events that occur in both pediatric hospital based and ambulatory care settings. It is flexible in its construction, permits analysis to begin at any point, and depicts the relationships and interactions of elements of an event.
safety taxonomy Anatomy of a patient safety event: a pediatric patient
Background: Idiosyncratic terminology and frameworks in the study of patient safety have been tolerated but are increasingly problematic. Agreement on standard language and frameworks is needed for optimal improvement and dissemination of knowledge about patient safety. Methods: Patient safety events were assessed using critical incident analysis, a method used to classify risks that has been more recently applied to medicine. Clinician interviews and clinician reports to a web based reporting system were used for analysis of hospital based and ambulatory care events, respectively. Events were classified independently by three investigators. Results: A pediatric patient safety taxonomy, relevant to both hospital based and ambulatory pediatric care, was developed from the analysis of 122 hospital based and 144 ambulatory care events. It is composed of four main categories: (1) problem type; (2) domain of medicine; (3) contributing factors in the patient (child-specific), environment (latent conditions) and care providers (human factors); and (4) outcome or result of the event and level of harm. A classification of preventive mechanisms was also developed. Inter-rater reliability of classifications ranged from 72% to 86% for sub-categories of the taxonomy. Conclusions: This patient safety taxonomy reflects the nature of events that occur in both pediatric hospital based and ambulatory care settings. It is flexible in its construction, permits analysis to begin at any point, and depicts the relationships and interactions of elements of an event.
Patient Safety in Pediatrics: a Developing Discipline
2011
markdownabstract__Abstract__ The publication of the breakthrough report “To Err is Human” by the Institute of Medicine was the launch of patient safety initiatives all over the world. In the intensive care unit (ICU) of the Erasmus MC-Sophia Children’s Hospital this resulted in the institution of a multimodal patient safety management system under the name Safety First in 2005. This system now includes nine major elements, representing monitoring and intervention activities. In this thesis we report on the results and the implementation of the patient safety management system called Safety First. __Outline of this thesis:__ In part I the concept of patient safety and the Safety First project are introduced. The rationale for selecting the elements of the patient safety management system is explained. As preventable mortality and morbidity are the public focus as outcome parameters for quality and safety of care, we have studied very long stay patients in our ICU (chapter 2). The goa...
Pediatric Patient Safety in the Prehospital/Emergency Department Setting
Pediatric Emergency Care, 2007
The unique characteristics of the pediatric population expose them to errors in the emergency department (ED) with few standard practices for the safety of care. Young children and highacuity patients are at increased risk of adverse events both in the prehospital and ED settings. We provide an overview of the problems and possible solutions to the threats to pediatric patient safety in the ED. Endorsing a culture of safety and training to work in a team are discussed. Medication errors can be reduced by using organizational systems, and manufacturing and regulatory systems, by educating health care providers, and by providing caregivers tools to monitor prescribing. The consensus is that a safe environment with a high quality of care will reduce morbidity and mortality in ED pediatric patients.
Patient Safety in paediatrics and neonatal medication
The Journal of Medical Research, 2016
Patient safety needs to be addressed for better health services. This needs a stringent uniform regulatory system. Although, after 2013 Central Drug Standard Control Organisation, CDSCO has laid down regulations for clinical trial, stem cells research, compensation for morbidity and mortality in subjects in clinical trial. There has been data from India on medication errors and patient safety in pediatric, neonatal and anaesthesia setting, knowledge of health professionals on medication errors. Still regulatory body has not laid down standards of patient safety, its audit, insurance and compensation guidelines. Medication errors are prevalent in the hospital settings. Considerable attention to patient safety is not a regular component of medical education, and much research needs to be carried out to understand the causes, consequences, and prevention of healthcare-related adverse events. Pediatric population is three times more suseptible to such errors. Healthcare professionals wo...
Chapter 15. Pediatric Safety and Quality
Pediatric inpatient safety and quality of care are dynamic and complex phenomena. Our intent is to inform the reader about efforts underway by pediatric stakeholders and specialty groups and to understand where credible information can be accessed pertaining to patient safety and quality in the provision of care for the hospitalized child. Over the past several years, pediatric groups have partnered to improve general understanding, reporting, process improvement methodologies, and quality of pediatric inpatient care. These collaborations have created a robust program of projects, benchmarking efforts, and research.
Pediatric Medication Errors: What Do We Know? What Gaps Remain?
Ambulatory Pediatrics, 2004
Ambulatory Pediatrics 2004;4:73 81 P atient safety is an increasingly well-recognized public health problem. The Institute of Medicine's report entitled To Err Is Human 1 initially drew widespread attention to this issue by estimating that approximately 44 000-98 000 deaths each year result from medical mistakes in hospitals. These estimates came from 2 main studies: the Harvard Medical Practice Study and the Colorado-Utah Study. 2-4 Even though controversy surrounds the extrapolation of these numbers to national estimates, most agree that patient safety can be significantly improved. The Harvard Medical Practice Study found that medication errors are the most frequent type of medical errors, comprising over 19% followed by wound infections (14%) and technical complications (13%). 2,3 This finding prompted further study of medication errors in adult inpatients, documenting a medication error rate of 5/100 medication orders, with 7 in 100 errors having a potential for injury (potential adverse drug event [ADE]) and 1 in 100 errors resulting in an ADE. 5 A later Adverse Drug Event Prevention Study documented 6.5 ADEs per 100 adult admissions. Other studies demonstrated that ADEs are costly and can have severe sequelae, 7,8 as well as high frequencies of medication errors in adult outpatients. In comparison, relatively few studies of medication errors have focused on children. In this article, we discuss why children are particularly prone to errors and review pediatric studies of medication errors. We then explore potential prevention strategies using a systems-based approach as advocated by the Institute of Medicine report, Crossing the Quality Chasm. 11 This report identified 6 specific aims for quality improvement in health care, with safety leading the list, and emphasized that ensuring safety requires a systems-based approach to the development and
Patient safety in ambulatory care
Pediatric clinics of North America, 2012
Understanding of the types and frequency of errors among children in the outpatient setting is paramount. The most commonly described errors involve medical treatment, communication failures, patient identification, laboratory, and diagnostic errors. Research suggests that adverse events and near misses are frequent occurrences in ambulatory pediatrics, but relatively little is known about the types of errors, risk factors, or effective interventions in this setting. This article will review current information on the descriptive epidemiology of pediatric outpatient medical errors, established risk factors for these errors, effective interventions to enhance reporting and improve safety, and future research needs in this area.
Therapeutic Advances in Drug Safety, 2018
Background: Hospitalized children are prone to experience harm from medication errors (MEs). Strategies to prevent MEs can be developed from identified malfunctioning practices and conditions in the medication use process. In this study, we aimed to identify MEs and potentially unsafe medication practices (PUMPs) in hospitalized children, and to assess the potential harm of these, using raters of different professions. Methods: A 1-week observation using an undisguised technique was conducted on four paediatric hospital wards. One observer followed ward staff during medication prescribing, preparation and administration. MEs and PUMPs were documented using field notes. Three raters including a physician, a nurse and a clinical pharmacist assessed the potential harm of each ME and PUMP using a six-point Likert scale. Agreement was analysed using Fleiss’ Kappa. Results: A total of 16 MEs and 809 PUMPs were identified involving a preparation and administration error rate of 8%. No actu...