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Safety on an inpatient pediatric otolaryngology service: Many small errors, few adverse events

Authors

  • Rahul K. Shah MD,

    Corresponding author
    1. Division of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine, Washington, D.C., U.S.A.
    • Division of Otolaryngology, Children's National Medical Center, 111 Michigan Avenue, NW, Washington, D.C. 20010
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  • Lina Lander ScD,

    1. Department of Epidemiology, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A.
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  • Peter Forbes PhD,

    1. Clinical Research Program, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, U.S.A.
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  • Kathy Jenkins MD, MPH,

    1. Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, U.S.A.
    2. Program for Patient Safety and Quality, Children's Hospital Boston, Boston, Massachusetts, U.S.A.
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  • Gerald B. Healy MD,

    1. Department of Otolaryngology and Communication Disorders, Children's Hospital Boston, Boston, Massachusetts, U.S.A.
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  • David W. Roberson MD

    1. Program for Patient Safety and Quality, Children's Hospital Boston, Boston, Massachusetts, U.S.A.
    2. Department of Otolaryngology and Communication Disorders, Children's Hospital Boston, Boston, Massachusetts, U.S.A.
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Abstract

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. Laryngoscope, 2009

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