PMID- 16140699
OWN - NLM
STAT- MEDLINE
DCOM- 20051213
LR  - 20061115
IS  - 1098-4275 (Electronic)
IS  - 0031-4005 (Linking)
VI  - 116
IP  - 3
DP  - 2005 Sep
TI  - Preventable adverse events in infants hospitalized with bronchiolitis.
PG  - 603-8
AB  - OBJECTIVE: To determine the incidence of preventable adverse events (AEs) and 
      near misses (NMs) among infants hospitalized for bronchiolitis at a pediatric 
      tertiary care hospital and the impact of these errors on hospital length of stay 
      (LOS). METHODS: We studied 143 infants with bronchiolitis, ages 0 to 12 months, 
      admitted from December 2002 to April 2003. Using prospective chart review and 
      staff reports, we captured medical errors and AEs. Each event was classified as a 
      (1) preventable AE, (2) nonpreventable AE, (3) intercepted NM, (4) nonintercepted 
      NM, or (5) error with little or no potential for harm. RESULTS: Of 143 patients, 
      15 (10%) suffered an AE or NM. The incidence of preventable AEs was 10 per 100 
      admissions. We found a higher incidence of preventable AEs and NMs among 
      critically ill patients (CIPs) compared with non-CIPs (68 vs 5 per 100 
      admissions, respectively), making the absolute risk of an AE or NM 14 times more 
      likely in CIPs. Mean LOS was significantly longer for CIPs with at least 1 AE 
      (9.1 +/- 8.8 days) than for CIPs without AEs (2.9 +/- 1.5 days). Mean LOS was not 
      significantly different between non-CIPs who did (3.8 +/- 2.6 days) and did not 
      (4.2 +/- 5.0 days) experience an AE. CONCLUSIONS: Preventable AEs occur 
      frequently among patients admitted for bronchiolitis, especially those who are 
      critically ill. CIPs who suffer AEs during their hospitalization have longer 
      hospital LOSs. Future studies should investigate error-prevention strategies with 
      a focus on those patients with severe disease.
FAU - McBride, Sarah C
AU  - McBride SC
AD  - Department of Medicine, Children's Hospital Boston, Boston, MA 02115, USA. 
      sarah.mcbride@childrens.harvard.edu
FAU - Chiang, Vincent W
AU  - Chiang VW
FAU - Goldmann, Donald A
AU  - Goldmann DA
FAU - Landrigan, Christopher P
AU  - Landrigan CP
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
PL  - United States
TA  - Pediatrics
JT  - Pediatrics
JID - 0376422
SB  - IM
MH  - Bronchiolitis/complications/*therapy
MH  - Critical Illness
MH  - *Hospitalization
MH  - Hospitals, Pediatric
MH  - Humans
MH  - Iatrogenic Disease/*epidemiology/prevention & control
MH  - Infant
MH  - Length of Stay
MH  - Medical Errors/prevention & control/*statistics & numerical data
EDAT- 2005/09/06 09:00
MHDA- 2005/12/15 09:00
CRDT- 2005/09/06 09:00
PHST- 2005/09/06 09:00 [pubmed]
PHST- 2005/12/15 09:00 [medline]
PHST- 2005/09/06 09:00 [entrez]
AID - 116/3/603 [pii]
AID - 10.1542/peds.2004-2387 [doi]
PST - ppublish
SO  - Pediatrics. 2005 Sep;116(3):603-8. doi: 10.1542/peds.2004-2387.