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Paediatrics
Research
Near misses and unsafe conditions reported in a Pediatric Emergency Research Network
  1. Richard M Ruddy1,
  2. James M Chamberlain2,
  3. Prashant V Mahajan3,
  4. Tomohiko Funai4,
  5. Karen J O'Connell2,
  6. Stephen Blumberg5,
  7. Richard Lichenstein6,
  8. Heather L Gramse4,
  9. Kathy N Shaw7,
  10. and the Pediatric Emergency Care Applied Research Network
    1. 1Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
    2. 2Department of Pediatrics, George Washington University School of Medicine, Children's National Medical Center, Washington DC, USA
    3. 3Children's Hospital of Michigan, Detroit, Michigan, USA
    4. 4Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
    5. 5Department of Pediatrics, Albert Einstein School of Medicine, New York, New York, USA
    6. 6Department of Pediatrics, University of Maryland, Baltimore, Maryland, USA
    7. 7University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    1. Correspondence to Dr Richard M Ruddy; Richard.ruddy{at}cchmc.org

    Abstract

    Objective 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).

    Design 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.

    Results 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%.

    Conclusions Medication and process-related issues are important causes of near miss and unsafe conditions in the network. 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.

    This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

    https://doi.org/10.1136/bmjopen-2014-007541

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