Paeds Cases · professional-practice-and-evidence
Safety station — infusion error rescue, incident report, systems analysis and family disclosure
Structured clinical encounter testing immediate rescue after a paediatric medication adverse event, blame-free incident reporting, systems analysis with strong actions, and open disclosure to the family.
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Study tools
Target exams
RACP General PaediatricsRACP DWERACP DCEMRCPCH ClinicalRCPSC Pediatrics
Prompt
Station A is the immediate clinical and safety response to a ten-fold opioid infusion error in a four-year-old. Station B is family disclosure, systems analysis and clinician welfare over the following hours.
Station objectives
- Execute an ordered clinical and safety response to an in-hospital adverse event. [2]
- Report in the local incident system and preserve evidence without blame. [1]
- Disclose to the family using open, honest communication principles. [14]
- Lead a systems analysis that prefers strong actions and supports the second victim. [1] [15]
References7ShowHide
- [1]Reason J Human error: models and management. The Western journal of medicine, 2000.PMID 10854390
- [2]Leape LL Error in medicine. JAMA, 1994.PMID 7503827
- [9]Takata GS Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics, 2008.PMID 18381521
- [11]Classen DC 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health affairs (Project Hope), 2011.PMID 21471476
- [13]Starmer AJ Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088
- [14]Gallagher TH Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA, 2003.PMID 12597752
- [15]Wu AW Medical error: the second victim. The Western journal of medicine, 2000.PMID 10854367