Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach

Frey, Bernhard; Kehrer, B.; Losa, M.; Braun, Helga Samara Ferreira; Berweger, L; Micallef, Julia; Ebenberger, M

doi:10.1007/s001340050014

Cited by 92 publications

(91 citation statements)

References 14 publications

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“…This agrees with other studies that reported that failure in medical devices was one of the causes of near misses in the NICU (26,27).…”

Section: Discussionsupporting

confidence: 93%

“…This agrees with a study that reported 61% minor errors, 26% moderate errors and 13% major errors (11). However, our results disagree with another study that reported 30% major errors (death or need for ICUspecific intervention), 25% moderate errors (requiring routine therapy available outside the ICU) and 45% minor errors (no intervention required) (27).…”

Section: Discussionsupporting

confidence: 70%

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Medical errors in neonatal intensive care unit at Benha University Hospital, Egypt

El-Shazly¹,

Al-Azzouny²,

Soliman³

et al. 2017

East Mediterr Health J

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This study was conducted in the neonatal intensive care unit of Benha University Hospital, Egypt from 1 August 2012 to the 31 January 2013 to identify medical errors and to determine the risk factors and consequences of these errors. Errors were detected by follow-up of neonates and review of reports including nursing followup sheets, resident progression notes and investigation reports. We detected 3819 errors that affected 97% of neonates. Types of errors included 403 medication errors (10.55% of total errors), 652 errors in daily routine procedures (17.07%), 1042 errors in invasive procedures (27.28%), 68 errors in nutrition (1.78%), 63 equipment errors (1.64%), 260 administration errors (6.8%), 656 staffing errors (17.18%), 107 environmental errors (2.8%), 448 infection control errors (11.73%) and 120 nosocomial infection errors (3.14%). Medical errors were high in low birth weight, low gestational age neonates and increased with duration of admission. RÉSUMÉ La présente étude a été conduite dans l'unité néonatale de soins intensifs du centre hospitalier universitaire de Banha, en Égypte, du 1 er août 2012 au 31 janvier 2013, dans le but d'identifier les erreurs médicales et de déterminer les facteurs de risque et les conséquences associés. Des erreurs ont été détectées dans le suivi des nouveau-nés et l'analyse de rapports incluant des fiches de suivi des soins infirmiers, des notes sur la progression des internes, et des rapports d'enquête. Nous avons détecté 3 819 erreurs ayant affecté 97 % des nouveau-nés. Les types d'erreurs incluaient 403 erreurs de médication (10,55 % du nombre total d'erreurs), 652 erreurs dans les actes de routine journaliers (17,07 %), 1 042 erreurs dans les procédures invasives (27,28 %), 68 erreurs de nutrition (1,78 %), 63 erreurs d'équipement (1,64 %), 260 erreurs administratives (6,8 %), 656 erreurs au niveau du personnel (17,18 %), 107 erreurs en matière de pratiques environnementales (2,8 %), 448 erreurs liées à la lutte contre les infections (11,73 %) et 120 erreurs entraînant des infections nosocomiales (3,14 %). Les erreurs médicales étaient nombreuses dans les cas de nouveau-nés souffrant d'une insuffisance pondérale à la naissance ou étant nés prématurément, et elles augmentaient en fonction de la durée de l'hospitalisation. ‫مرص‬

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“…This agrees with other studies that reported that failure in medical devices was one of the causes of near misses in the NICU (26,27).…”

Section: Discussionsupporting

confidence: 93%

Section: Discussionsupporting

confidence: 70%

Medical errors in neonatal intensive care unit at Benha University Hospital, Egypt

El-Shazly¹,

Al-Azzouny²,

Soliman³

et al. 2017

East Mediterr Health J

View full text Add to dashboard Cite

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“…Transcription errors were not commonly reported within paediatric studies, with only three articles acknowledging their incidence [Frey et al 2000[Frey et al , 2002Fortescue et al 2003]. These types of errors made up 5.8% of all medication errors, and included: punctuation mistakes (i.e.…”

Section: Paediatricmentioning

confidence: 99%

“…writing '3' instead of '0.3'), omission of medication, wrong unit of measurement (i.e. g instead of mg) and incorrect doses [Frey et al 2000[Frey et al , 2002Fortescue et al 2003]. …”

Section: Paediatricmentioning

confidence: 99%

Medication safety in neonatal care: a review of medication errors among neonates

Krzyżaniak

Bajorek

2016

Therapeutic Advances in Drug Safety

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Objective: The objective of this study was to describe the medication errors in hospitalized patients, comparing those in neonates with medication errors across the age spectrum. Method: In tier 1, PubMed, Embase and Google Scholar were searched, using selected MeSH terms relating to hospitalized paediatric, adult and elderly populations. Tier 2 involved a search of the same electronic databases for literature relating to hospitalized neonatal patients. Results: A total of 58 articles were reviewed. Medication errors were well documented in each patient group. Overall, prescribing and administration errors were most commonly identified across each population, and mostly related to errors in dosing. Errors due to patient misidentification and overdosing were particularly prevalent in neonates, with 47% of administration errors involving at least tenfold overdoses. Unique errors were identified in elderly patients, comprising duplication of therapy and unnecessary prescribing of medicines. Overall, the medicines most frequently identified with error across each patient group included: heparin, antibiotics, insulin, morphine and parenteral nutrition. While neonatal patients experience the same types of medication errors as other hospitalized patients, the medication-use process within this group is more complex and has greater consequences resulting from error. Suggested strategies to help overcome medication error most commonly involved the integration of a clinical pharmacist into the treating team. Conclusion: This review highlights that each step of the medication-use process is prone to error across the age spectrum. Further research is required to develop targeted strategies relevant to specific patient groups that integrate key pharmacy services into wards.

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“…When formatted as a nonhierarchical tool inviting contributions from all staff levels, the morbidity and mortality conference plays a key role in the system approach to medical errors. (Pediatr Crit Care Med 2016; 17:67-72) Key Words: adverse events; error and risk analysis; medical error; morbidity and mortality conference; patient safety; pediatric intensive care unit T he morbidity and mortality conference (MMC) served traditionally as an educational aid for medical trainees, but more recently, new emphasis has been placed on patient safety and quality improvement (1)(2)(3)(4)(5)(6)(7)(8), including critical incident monitoring (9), error and risk analysis (10), postincident team debriefings, and the monitoring of quality indicators and adverse events (11). By identifying adverse events and their cause(s), the MMC prompts intervention and may prevent patient harm (8,12,13).…”

Section: Measurements and Main Resultsmentioning

confidence: 99%

The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

Frey

Doell

Klauwer

et al. 2016

Pediatric Critical Care Medicine

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OBJECTIVES: To present our experience in an interdisciplinary and interprofessional morbidity and mortality conference, with special emphasis on its usefulness in improving patient safety. DESIGN: Retrospective analysis. SETTING: Tertiary interdisciplinary neonatal PICU. PATIENTS: Morbidity and mortality conference minutes on 48 patients (newborns to 17 yr), January 2009 to June 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors' PICU implemented a morbidity and mortality conference guideline in 2009 using a system-based approach to identify medical errors, their contributing factors, and possible solutions. In the subsequent 5.5 years, there were 44 mortality conferences (of 181 deaths [27%] over the same period) and four morbidity conferences. The median death/morbidity event-morbidity and mortality conference interval was 90 days (range, 7 d to 1.5 yr). The median age of patients was 4 months (range, newborn to 17 years). In six cases, the primary reason for PICU admission was a treatment complication. Unsafe processes/medical errors were identified and discussed in 37 morbidity and mortality conferences (77%). In seven cases, new autopsy findings prompted the discussion of a possible error. The 48 morbidity and mortality conferences identified 50 errors, including 30 in which an interface problem was a contributing factor. Fifty-four improvements were identified in 34 morbidity and mortality conferences. Four morbidity and mortality conferences discussed specific ethical issues. CONCLUSIONS: From our experience, we have found that the interdisciplinary and interprofessional morbidity and mortality conference has the potential to reveal unsafe processes/medical errors, in particular, diagnostic and communication errors and interface problems. When formatted as a nonhierarchical tool inviting contributions from all staff levels, the morbidity and mortality conference plays a key role in the system approach to medical errors. Originally published at: Frey, Bernhard; Doell, Carsten; Klauwer, Dietrich; Cannizzaro, Vincenzo; Bernet, Vera; Maguire, Christine; Brotschi, Barbara (2016). The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety. Pediatric Critical Care Medicine, 17(1):67-72.

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Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach

Abstract: CIs are very common in pediatric intensive care. Knowledge of them is a precious source for quality improvement through changes in the system.

Cited by 92 publications

References 14 publications

Medical errors in neonatal intensive care unit at Benha University Hospital, Egypt

Medical errors in neonatal intensive care unit at Benha University Hospital, Egypt

Medication safety in neonatal care: a review of medication errors among neonates

The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

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