PMID- 19358191
OWN - NLM
STAT- MEDLINE
DCOM- 20090605
LR  - 20090427
IS  - 1531-4995 (Electronic)
IS  - 0023-852X (Linking)
VI  - 119
IP  - 5
DP  - 2009 May
TI  - Safety on an inpatient pediatric otolaryngology service: many small errors, few 
      adverse events.
PG  - 871-9
LID - 10.1002/lary.20208 [doi]
AB  - OBJECTIVES: Studies of medical error demonstrate that errors and adverse events 
      (AEs) are common in hospitals. There are little data of errors on pediatric 
      surgical services. METHODS: We retrospectively reviewed 50 randomly selected 
      inpatient admissions to the otolaryngology service at a tertiary care children's 
      hospital. We used a "zero-defect" paradigm, recording any error or adverse 
      event-from minor errors such as illegible notes to more significant errors such 
      as mismanagement resulting in a bleeding emergency. RESULTS: A total of 553 
      errors/AEs were identified in 50 admissions. Most (449) were charting or 
      record-keeping deficiencies. Minor AEs (n = 26) and moderate AEs (n = 8) were 
      present in 38% of admissions; there were no major AEs or permanent morbidity. 
      Medication-related errors occurred in 22% of admissions, but only two resulted in 
      minor AEs. There was a positive correlation between minor errors and AEs; 
      however, this was not statistically significant. CONCLUSIONS: Multiple errors 
      occurred in every inpatient pediatric otolaryngology admission; however, only 26 
      minor and eight moderate AEs were identified. The rate of errors per 1,000 
      hospital days (6,356 per 1,000 days) is higher than previously reported in 
      voluntary reporting studies, possibly due to our methodology of physician review 
      with a "zero-defect" standard. Trends in the data suggest that the presence of 
      small errors may be associated with the risk of adverse events. Although 
      labor-intensive, physician chart review is a valuable tool for identifying areas 
      for improvement. Although small errors were common, there were few harms and no 
      major morbidity.
FAU - Shah, Rahul K
AU  - Shah RK
AD  - Division of Otolaryngology, Children's National Medical Center, George Washington 
      University School of Medicine, Washington, DC 20010, USA. rshah@cnmc.org
FAU - Lander, Lina
AU  - Lander L
FAU - Forbes, Peter
AU  - Forbes P
FAU - Jenkins, Kathy
AU  - Jenkins K
FAU - Healy, Gerald B
AU  - Healy GB
FAU - Roberson, David W
AU  - Roberson DW
LA  - eng
PT  - Journal Article
PL  - United States
TA  - Laryngoscope
JT  - The Laryngoscope
JID - 8607378
SB  - IM
MH  - Adolescent
MH  - Causality
MH  - Child
MH  - Child, Preschool
MH  - Female
MH  - *Hospitals, Pediatric
MH  - Humans
MH  - Infant
MH  - Male
MH  - Medical Errors/classification/prevention & control/*statistics & numerical data
MH  - Otolaryngology/*standards
MH  - Quality Assurance, Health Care
MH  - Retrospective Studies
MH  - *Safety Management
MH  - Young Adult
EDAT- 2009/04/10 09:00
MHDA- 2009/06/06 09:00
CRDT- 2009/04/10 09:00
PHST- 2009/04/10 09:00 [entrez]
PHST- 2009/04/10 09:00 [pubmed]
PHST- 2009/06/06 09:00 [medline]
AID - 10.1002/lary.20208 [doi]
PST - ppublish
SO  - Laryngoscope. 2009 May;119(5):871-9. doi: 10.1002/lary.20208.