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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

Graph of the near miss and unsafe condition incident reports by category reported
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BMJOPEN2014007541F5: Graph of the near miss and unsafe condition incident reports by category reported

Mentions: FigureĀ 5 depicts the numbers of IRs from all reporting sites by type or category and separate bars for near miss and unsafe conditions. Medication near misses predominate, followed closely by laboratory, radiology and process-related IRs. Many of these were entered in the IR reporting system by staff outside of the ED. Within IRs reported as unsafe conditions, process-related IRs predominated with a modest number of the other categories. There were very few IRs categorised as near miss or unsafe conditions regarding ED use of blood products or specific medical procedures.


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)

Graph of the near miss and unsafe condition incident reports by category reported
© Copyright Policy - open-access
Related In: Results  -  Collection

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

BMJOPEN2014007541F5: Graph of the near miss and unsafe condition incident reports by category reported
Mentions: FigureĀ 5 depicts the numbers of IRs from all reporting sites by type or category and separate bars for near miss and unsafe conditions. Medication near misses predominate, followed closely by laboratory, radiology and process-related IRs. Many of these were entered in the IR reporting system by staff outside of the ED. Within IRs reported as unsafe conditions, process-related IRs predominated with a modest number of the other categories. There were very few IRs categorised as near miss or unsafe conditions regarding ED use of blood products or specific medical procedures.

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