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

Ruddy RM, Chamberlain JM, Mahajan PV, Funai T, O'Connell KJ, Blumberg S, Lichenstein R, Gramse HL, Shaw KN, Pediatric Emergency Care Applied Research Netwo - BMJ Open (2015)

Bottom Line: Handoff issues were important in 11.5%.Human factors issues were highly reported and non-compliance with established procedures was very common, and calculation issues, communications (ie, handoffs) and clinical judgment were also important.This work should enable us to help improve systems within the environment of the ED to enhance patient safety in the future.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

No MeSH data available.


Related in: MedlinePlus

Number of near miss incident reports (IRs) per 1000 patient visits by site.
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BMJOPEN2014007541F2: Number of near miss incident reports (IRs) per 1000 patient visits by site.

Mentions: Figures 2 and 3 depict the rates for each of near misses and unsafe condition for all 18 hospitals, expressed as reports per 1000 patients. The rate of reporting for unsafe conditions and near misses ranged from 0.0 to 1.43 per 1000 ED visits among the 18 hospitals. There were two sites with no IRs classified as near misses (K, M) or unsafe conditions (F, T) by the principal investigators and several sites with very low rates. Figure 4 shows the overall monthly rates per 1000 visits of IRs of near misses and unsafe conditions, which did not demonstrate substantial change over the year studied, despite an overall increase of all IRs in the 18 reporting EDs.


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

Ruddy RM, Chamberlain JM, Mahajan PV, Funai T, O'Connell KJ, Blumberg S, Lichenstein R, Gramse HL, Shaw KN, Pediatric Emergency Care Applied Research Netwo - BMJ Open (2015)

Number of near miss incident reports (IRs) per 1000 patient visits by site.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4563227&req=5

BMJOPEN2014007541F2: Number of near miss incident reports (IRs) per 1000 patient visits by site.
Mentions: Figures 2 and 3 depict the rates for each of near misses and unsafe condition for all 18 hospitals, expressed as reports per 1000 patients. The rate of reporting for unsafe conditions and near misses ranged from 0.0 to 1.43 per 1000 ED visits among the 18 hospitals. There were two sites with no IRs classified as near misses (K, M) or unsafe conditions (F, T) by the principal investigators and several sites with very low rates. Figure 4 shows the overall monthly rates per 1000 visits of IRs of near misses and unsafe conditions, which did not demonstrate substantial change over the year studied, despite an overall increase of all IRs in the 18 reporting EDs.

Bottom Line: Handoff issues were important in 11.5%.Human factors issues were highly reported and non-compliance with established procedures was very common, and calculation issues, communications (ie, handoffs) and clinical judgment were also important.This work should enable us to help improve systems within the environment of the ED to enhance patient safety in the future.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

No MeSH data available.


Related in: MedlinePlus