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


METHODS
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.
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Richard M
RM
Ruddy
Department of Pediatrics, George Washington University School of Medicine, Children's National Medical Center, Washington DC, USA.
James M
JM
Chamberlain
Children's Hospital of Michigan, Detroit, Michigan, USA.
Prashant V
PV
Mahajan
Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.
Tomohiko
T
Funai
Department of Pediatrics, George Washington University School of Medicine, Children's National Medical Center, Washington DC, USA.
Karen J
KJ
O'Connell
Department of Pediatrics, Albert Einstein School of Medicine, New York, New York, USA.
Stephen
S
Blumberg
Department of Pediatrics, University of Maryland, Baltimore, Maryland, USA.
Richard
R
Lichenstein
Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.
Heather L
HL
Gramse
University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Kathy N
KN
Shaw
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D019300:Medical Errors / Q000706:statistics & numerical data*; D061214:Patient Safety / Q000706:statistics & numerical data*; D014481:United States