Paeds · professional-practice-and-evidence
Patient safety, human factors and systems thinking
Also known as Patient safety in paediatrics · Human factors and ergonomics in healthcare · Systems thinking and the Swiss cheese model · Just culture and the second victim · Adverse events and incident reporting
Fellowship guide to patient safety, human factors and systems thinking in paediatrics: the language of adverse events, near misses, never events and sentinel events; Reason's Swiss cheese model and the system-versus-person approach; why children are at heightened risk and the medication-safety evidence (Kaushal, Stucky, Potts); proven reliability interventions (central-line bundle, WHO surgical checklist, I-PASS handover); the adverse-event response pathway, root cause analysis, open disclosure, just culture and the second victim; and ANZ, UK, US and Canada frameworks.
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Target exams
Red flags
- A child who is deteriorating with documented abnormal observations that no one escalated — failure to rescue
- Repeated workarounds around a flawed process, or a string of near misses with no incident reports
- A weight-based paediatric dose calculated without an independent double-check of a high-alert medicine
- A clinician involved in an adverse event who is withdrawn, anxious or sleepless — an unrecognised second victim
- A 'blame-the-nurse' or 'blame-the-doctor' reaction after harm, with no examination of the system that allowed the error through
- An investigation that ends at the individual ('staff failed to…') instead of the latent conditions that set them up to fail
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics — quality and safety themes
- Acute and critical paediatrics — recognising and responding to the deteriorating child
- Professional practice: ethics, quality and patient safety
- Renewed curriculum — Leading and improving care: clinical governance, patient safety and quality improvement
- Medication safety and human factors in complex and chronic paediatric illness
- Professional practice, ethics and medico-legal principles after an adverse event
- Quality and safety in general and community paediatrics
- Written assessment of patient-safety principles, error taxonomy and systems thinking
- Long Cases involving a child with a serious safety event or complex medication needs
- Structured discussion of root cause analysis and open disclosure
- Communication stations: escalating a deteriorating child (SBAR) and disclosing harm
- 2. Professional skills and knowledge: quality improvement and patient safety
- 3. Areas of practice — safe use of medicines and managing clinical risk
- Leadership and team working: speaking up, handover and human factors
- Foundation of Practice (FOP) — patient safety and quality
- Applied Knowledge in Practice (AKP) — medication safety, error and systems thinking
- Communication: escalating concerns and structured handover
- History taking and management: open disclosure and managing an adverse event
- Safe prescribing and the deteriorating child
- General Pediatrics Content Outline — patient safety and quality improvement
- General Pediatrics Content Outline — safe and effective prescribing in children
- Systems-based practice and the high-reliability organisation
- Systems-Based Practice: clinical governance, error and systems thinking
- Practice-Based Learning and Improvement: root cause analysis and quality improvement
- Patient Care and professionalism: open disclosure and the second victim
- Collaborator and Communicator — handover, escalation and disclosure
- Leader — patient safety, quality and clinical governance
- Pediatric EPA — safe prescribing and recognising the deteriorating child
The two ways to see an error
Person approach (the trap)
The shared rule
Harm = an active failure (sharp end) passing through aligned holes in the latent conditions (blunt end). The holes are made by workload, fatigue, poor design and production pressure; the layers are organisation, supervision, preconditions and acts. Build the layers, shrink the holes. [3]
Overview & Definition
A three-year-old on the ward receives ten times the intended morphine because a decimal point was misread in a handwritten chart, and he stops breathing. A teenager is sent home with a missed appendix because the team anchored to "gastroenteritis." A baby in the NICU gets the wrong concentration of adrenaline from a look-alike ampoule. None of these is, at its heart, a story about a bad doctor or a careless nurse. Each is a story about a system whose defences did not catch a fallible human act before it reached a child. [3] [6]
Patient safety is the prevention of harm caused by the health system rather than by the disease itself. The Harvard Medical Practice Study, which reviewed 30,000 hospital records, found that nearly 4% of admissions involved an adverse event and that around seven in ten were preventable — harm caused not by the illness but by the care meant to treat it. [1] [2] The Institute of Medicine's To Err Is Human reframed those numbers as a public health emergency and shifted the question from "who is to blame?" to "what made this possible?" [3]
The defining idea of this whole field is systems thinking: human error is inevitable, so safety lives in the layers built around people, not in the demand that people never err. Reason put it plainly — you can choose the person approach (blame individuals, rely on perfect performance) or the system approach (build defences that expect and catch human fallibility). Only the second one works. [3]
This page owns the science and practice of patient safety as it applies to children: the language of events and errors, the Swiss cheese model of harm, why paediatrics is high-risk, the interventions proven to reduce harm, and the fixed sequence that follows an adverse event. Cross-link the dedicated leaves for adverse-event reporting and medication-safety detail, for breaking bad news, and for shared decision-making and consent — this page builds the framework, it does not rebuild theirs. [3] [12]
References13ShowHide
- [1]Brennan TA Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. The New England journal of medicine, 1991.PMID 1987460
- [2]Leape LL The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. The New England journal of medicine, 1991.PMID 1824793
- [3]Reason J Human error: models and management. BMJ (Clinical research ed.), 2000.PMID 10720363
- [4]Wu AW Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ (Clinical research ed.), 2000.PMID 10720336
- [5]Leonard M The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality & safety in health care, 2004.PMID 15465961
- [6]Kaushal R Medication errors and adverse drug events in pediatric inpatients. JAMA, 2001.PMID 11311101
- [7]Fortescue EB Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics, 2003.PMID 12671103
- [8]Stucky ER Prevention of medication errors in the pediatric inpatient setting. Pediatrics, 2003.PMID 12897304
- [9]Potts AL Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics, 2004.PMID 14702449
- [10]Haynes AB A surgical safety checklist to reduce morbidity and mortality in a global population. The New England journal of medicine, 2009.PMID 19144931
- [11]Pronovost P An intervention to decrease catheter-related bloodstream infections in the ICU. The New England journal of medicine, 2006.PMID 17192537
- [12]Vincent C Understanding and responding to adverse events. The New England journal of medicine, 2003.PMID 12637617
- [13]Starmer AJ Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088