Paeds · professional-practice-and-evidence
Recognition, reporting and analysis of adverse events
Also known as Paediatric incident reporting · Adverse event analysis children · Near miss reporting paediatrics · Trigger tool paediatric safety · Patient harm investigation children
Fellowship guide to recognising, reporting and analysing paediatric adverse events and near misses: systems thinking, trigger tools, disclosure principles, second-victim support, closed-loop learning and exam defence.
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Target exams
Red flags
- Ongoing hazard still harming the child or other patients
- Serious harm without senior escalation or family communication
- Deliberate concealment or alteration of records
- Cluster of similar incidents with no systems action
- Second-victim clinician left unsupported after a crisis
- Mandatory external notification delayed against local policy
- Blame-only response that suppresses further reporting
Life stages
Care settings
Clinical exam formats
Board mappings
- Professional qualities
- Patient safety and quality
- Ethics and communication
- Learning goal essential general paediatrics
- Quality and safety
- Professional practice
- Professional Qualities
- Clinical Applications
- Communication
- Long Cases
- Short Cases
- Patient safety
- Leadership and team working
- Quality improvement
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- History
- Clinical
- General Pediatrics Content Outline — Patient Safety and Quality Improvement
- General Pediatrics EPA: Identify system failures and contribute to improvement
- Systems-based practice
- Systems-Based Practice 1: Patient Safety and Quality Improvement
- Systems-Based Practice 2: System Navigation
- Professionalism 1: Professional Behavior
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Practice-Based Learning and Improvement 1
- Medical Expert
- Leader
- Communicator
- Professional
- Pediatrics: Collaborator and patient safety competencies
Overview & Definition
A toddler’s infusion is running at ten times the ordered rate. The nurse stops the pump. The child is pale. Your first job is clinical rescue. Your second job is recognition, reporting and analysis of an adverse event so the next child is safer. This leaf owns that pathway. Deep human-factors theory also lives on the patient-safety systems page; dosing mechanics live on medication safety. [1] [2]
An adverse event (AE) is unintended injury or complication caused by health care management rather than the child’s disease alone. A preventable AE is one that could have been avoided with currently accepted practice. A near miss is an event that could have caused harm but did not, often because someone caught it. An error is a failure of a planned action; not every error causes harm, and not every AE is caused by a single person’s slip. [2] [3] [5]
References18ShowHide
- [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
- [3]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
- [4]Vincent C Adverse events in British hospitals: preliminary retrospective record review. BMJ (Clinical research ed.), 2001.PMID 11230064
- [5]Woods D Adverse events and preventable adverse events in children. Pediatrics, 2005.PMID 15629994
- [6]Matlow AG Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 2012.PMID 22847964
- [7]Stockwell DC Adverse Events in Hospitalized Pediatric Patients. Pediatrics, 2018.PMID 30006445
- [8]Sharek PJ Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool. Pediatrics, 2006.PMID 17015521
- [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
- [10]Kirkendall ES Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. Pediatrics, 2012.PMID 23045558
- [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
- [12]Landrigan CP Temporal trends in rates of patient harm resulting from medical care. The New England journal of medicine, 2010.PMID 21105794
- [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
- [16]Pronovost P An intervention to decrease catheter-related bloodstream infections in the ICU. The New England journal of medicine, 2006.PMID 17192537
- [17]Kuo DZ Recognition and Management of Medical Complexity. Pediatrics, 2016.PMID 27940731
- [18]Turchi RM Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics, 2014.PMID 24777209