Pediatric safety incidents from an intensive care reporting system

Julia Lynn Skapik, Peter J Pronovost, Marlene R Miller, David A Thompson, Albert W Wu
Journal of Patient Safety 2009, 5 (2): 95-101

OBJECTIVES: Adverse events impose a great burden on patients and the health care system, but not enough is known about how to address incidents involving pediatric patients. This study examined the demographic factors, types of events, contributing system factors, and harm associated with incidents that occur in pediatric intensive care units.

METHODS: Cross-sectional analysis of 2 years of data on all pediatric safety incidents and near misses reported to the voluntary provider-recorded Intensive Care Unit Safety Reporting System in regards to harm and contributing factors.

RESULTS: In 464 incidents reported from 23 intensive care units to the Intensive Care Unit Safety Reporting System, patients were physically injured in one third of incidents and harmed in some way in two thirds of incidents. Medication errors were the most common incident type, but were associated with less harm than other event types. Line, tube, and airway events comprised one third of incidents and were associated with more harm than other types. Patient contributing factors were a strong predictor of harm; training and education factors were also commonly cited. In multivariate analysis, patient factors were the strongest predictor of harm adjusting for age, sex, and race.

CONCLUSIONS: Pediatric patients are commonly harmed in intensive care units. There are several potential ways to improve safety including protocols for high-risk procedures involving lines and tubes, improved monitoring, and staffing, training and communication initiatives. Providers may be able to identify patients at increased risk for harm and intervene to protect patient safety.

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