Building safer systems through critical occurrence reviews: nine years of learning.
At The Hospital for Sick Children (SickKids), the term critical occurrence was developed to describe any event that results in an actual or potential serious, undesirable and unexpected patient or staff outcome including death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition. It also includes a breach of legislation including the Personal Health Information Protection Act of Ontario. Although broader in its definition, the term aligns closely with critical incident as defined within the amendments to Regulation 965, under the Public Hospitals Act (Government of Ontario 1990). Critical occurrences may include (but are not limited to) potential or actual adverse outcomes (including death) associated with or resulting from medication errors; a wrong site, patient or procedure performed; contaminated drugs, devices or products; an equipment malfunction; an outbreak or unusual pattern/type of nosocomial infection; employee actual or potentially serious injuries.
Stevens
Polly
P
Department of Quality and Risk Management, The Hospital for Sick Children, University of Toronto, Toronto.
Campbell
Janice
J
Urmson
Lynn
L
Damignani
Rita
R
D003695:Delivery of Health Care; D019300:Medical Errors / Q000517:prevention & control*; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D012189:Retrospective Studies; D017751:Safety Management