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]

Paediatrics Fellowship Pro

You have read the opening of this case. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References7Show ledger

[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

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]

Paediatrics Fellowship Pro

You have read the opening of this case. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References7Show ledger

[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

Safety station — infusion error rescue, incident report, systems analysis and family disclosure

Station objectives

Safety station — infusion error rescue, incident report, systems analysis and family disclosure

Station objectives