Design and implementation of a near-miss reporting system at a large, academic pediatric anesthesia department.
Paediatr Anaesth
; 21(7): 810-4, 2011 Jul.
Article
en En
| MEDLINE
| ID: mdl-21535298
ABSTRACT
BACKGROUND:
Current incident reporting systems encourage retrospective reporting of morbidity and mortality and have low participation rates. A near miss is an event that did not cause patient harm, but had the potential to. By tracking and analyzing near misses, systems improvements can be targeted appropriately, and future errors may be prevented.METHODS:
An electronic, web based, secure, anonymous reporting system for anesthesiologists was designed and instituted at The Children's Hospital, Denver. This portal was compared to an existing hospital incident reporting system.RESULTS:
A total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period 1 year ago.CONCLUSION:
An anesthesia-specific anonymous near-miss reporting system, which eases and facilitates data entry and can prospectively identify processes and practices that place patients at risk, was implemented at a large, academic, freestanding children's hospital. This resulted in a dramatic increase in reported events and provided data to target and drive quality and process improvement.
Texto completo:
1
Colección:
01-internacional
Banco de datos:
MEDLINE
Asunto principal:
Pediatría
/
Gestión de Riesgos
/
Centros Médicos Académicos
/
Servicio de Anestesia en Hospital
Tipo de estudio:
Etiology_studies
/
Prognostic_studies
/
Risk_factors_studies
Límite:
Child
/
Humans
País/Región como asunto:
America do norte
Idioma:
En
Revista:
Paediatr Anaesth
Asunto de la revista:
ANESTESIOLOGIA
/
PEDIATRIA
Año:
2011
Tipo del documento:
Article
País de afiliación:
Estados Unidos