A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement

Understanding Patient and Clinician Reported Nonroutine Events in Ambulatory Surgery

“…(3) associated with other patient outcome measures; (4) associated with important clinician performance-shaping factors like workload, distractions, and poor usability; and (5) captured a wide cross-section of system failures. [16][17][18][19][20][21][22] This is the first study to describe the incidence and nature of patient-reported NREs during ambulatory surgery concurrently with NREs reported by the clinicians caring for these patients. To further delineate differences between patients' and clinicians' perspectives of the care delivered, we trained both clinicians and patients to assess and code the reported NREs.…”

“…An NRE is defined as any event that deviates from optimal or expected care for a specific patient in a specific clinical situation 7,13–15 . Studies have found that clinician-reported NREs are as follows: (1) frequent (≥1 NRE in 20%–40% of all care periods studied); (2) reliably reported (based on observer validation and video recordings of care episodes); (3) associated with other patient outcome measures; (4) associated with important clinician performance-shaping factors like workload, distractions, and poor usability; and (5) captured a wide cross-section of system failures 16–22 …”

Learning from Non-Routine Events and Teamwork in Intensive Care Units: Challenges and Opportunities

“…Studies show that teams of high performance are more resilient to display effective teamwork when NREs occur [4,6]. It has been hypothesized that the majority of NREs do not lead to adverse events because they are proactively identified, addressed, and mitigated by teams before they become or cause adverse events [3,6]. Recently, we found ICU team structures, such as the familiarity between teammates, are associated with their awareness of NREs [4].…”

“…Patients admitted to intensive care units (ICUs) have profound and complex illnesses, often fraught with uncertainties in diagnoses, treatments, and care decisions [2]. Clinicians often deviate from best practices to handle ICUs' myriad complexities and uncertainties [3,4]. Thus, NREs, a double-edged sword, may allow clinicians to neutralize potential failures; meanwhile, NREs may lead to unintended consequences or induce patient safety events (PSEs).…”

“…Detecting NREs and analyzing teamwork and time-dependent tasks performed by teams to handle NREs have been a more effective and feasible approach for performance improvement than traditional root cause analysis for patient safety events. However, studies to date have not investigated NREs in the contexts of teamwork and time-dependent tasks that are frequently associated with NREs [1][2][3][4][5][6]. Therefore, NREs serving as substantial evidence for an upstream interventional area to analyze PSEs have not been well explored.…”