title: Paediatric critical incident analysis: lessons learnt on analysis, recommendations and implementation.
abstract: The objectives of this study were to identify causal and contributing factors of serious patient safety incidents in a paediatric university hospital, to report on ensuing recommendations and to assess the extent of implementation of the recommendations. The possible causal and contributing factors identified in 17 incidents were classified by a system devised by Vincent et al. Proposed recommendations were classified by the same system, and degrees of implementation were established. A median of 5 causal and contributing factors per incident were identified. Twenty-two percent of all factors were related to teamwork and 22 % to task factors. A median of 5 recommendations per analysis were formulated. Most recommendations were related to task factors (36 %). The time load of each analysis was a mean of 27 h. One third of the recommendations have been acted upon, mostly those related to task and team factors.
  
  
  CONCLUSIONS
  Incident analysis is time-consuming but yields indispensable information on causal and contributing factors, presenting numerous opportunities for quality improvement. The value of these analyses could be improved by appointing responsibilities and setting up time frames for implementation. A bottom-up approach with managerial support appears to be a key to turning incident analysis and quality improvement into an ongoing process.
authors.affiliation: Intensive Care Unit, Erasmus MC Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands, c.vanderstarre@erasmusmc.nl.
authors.forename: Cynthia
authors.initials: C
authors.lastname: van der Starre
authors.forename: Monique
authors.initials: M
authors.lastname: van Dijk
authors.forename: Ada
authors.initials: A
authors.lastname: van den Bos
authors.forename: Dick
authors.initials: D
authors.lastname: Tibboel
mesh_terms: D003422:Critical Care / Q000458:organization & administration*; D003625:Data Collection; D004282:Documentation; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D015278:Intensive Care Units, Pediatric / Q000458:organization & administration; D019300:Medical Errors / Q000517:prevention & control; D009426:Netherlands; D061214:Patient Safety; D011785:Quality Assurance, Health Care / Q000458:organization & administration; D012189:Retrospective Studies; D017751:Safety Management / Q000458:organization & administration*