Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report.

Peter Lachman; Lynette Linkson; Trish Evans; Henning Clausen; Daljit Hothi

Study

Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report.

April 15, 2015

Lachman P, Linkson L, Evans T, et al. BMJ Qual Saf. 2015;24(5):337-44.

View more articles from the same authors.

Through an iterative process, researchers developed and tested a simple tool for patients and family members to report potential harms during hospitalization. The tool led to some improvements in staff reporting and other safety behaviors, but there was no measurable change in safety culture scores for the ward during the study period. This tool is an example of the increasingly utilized strategy of engaging patients in preventing errors.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Effectively leading for quality.

October 4, 2017

Reclaiming the systems approach to paediatric safety.

April 10, 2019

Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database.

April 7, 2010

Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool.

July 16, 2014

Equipped: overcoming barriers to change to improve quality of care (theories of change).

March 18, 2015

From harm to hope and purposeful action: what could we do after Francis?

July 23, 2014

Adverse drug event surveillance and drug withdrawals in the United States, 1969-2002.

July 6, 2005

COVID-19: patient safety and quality improvement skills to deploy during the surge.

June 24, 2020

The application of the Global Trigger Tool: a systematic review.

October 26, 2016

Learning in action: developing safety improvement capabilities through action learning.

September 25, 2013

Development of the Huddle Observation Tool for structured case management discussions to improve situation awareness on inpatient clinical wards.

May 30, 2018

The H-PEPSS: an instrument to measure health professionals' perceptions of patient safety competence at entry into practice.

June 13, 2012

Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "Good Catch" awards.

August 1, 2012

The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis.

October 13, 2021

Sterile compounding: clinical, legal, and regulatory implications for patient safety.

February 4, 2015

Quality assessment of spontaneous triggered adverse event reports received by the Food and Drug Administration.

March 14, 2012

An iconic language for the graphical representation of medical concepts.

May 14, 2008

Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members.

September 8, 2010

A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.

February 11, 2009

Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy.

May 26, 2010

Development and validation of a taxonomy of adverse handover events in hospital settings.

February 18, 2015

Designing and implementing a comprehensive quality and patient safety management model: a paradigm for perioperative improvement.

June 4, 2008

Assessing clinical handover between paramedics and the trauma team.

September 30, 2009

An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.

February 23, 2011

Policy and the future of adverse event detection using information technology.

March 6, 2005

Drug dosing error with drops – severe clinical course of codeine intoxication in twins.

November 5, 2008

A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

January 21, 2009

Comparison of computerized surveillance and manual chart review for adverse events.

June 29, 2011

Development of an electronic pediatric all-cause harm measurement tool using a modified Delphi method.

December 7, 2016

Can social media be used as a hospital quality improvement tool?

October 21, 2015

Outcomes of care by hospitalists, general internists, and family physicians.

January 2, 2008

Incident learning in radiation oncology: a review.

August 15, 2018

High-reliability organisation principles implemented in dentistry.

July 27, 2022

A novel approach to implementation of quality and safety programmes in anaesthesiology.

December 7, 2011

Factors contributing to an increase in duplicate medication order errors after CPOE implementation.

August 17, 2011

Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital.

June 12, 2013

Physician characteristics, attitudes, and use of computerized order entry.

August 23, 2006

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

June 7, 2006

Disclosing medical errors: prioritising the needs of patients and families.

July 5, 2023

The role of language barriers on efficacy of rapid response teams.

March 1, 2023

Impact of duty hour limits on resident training in otolaryngology.

June 15, 2005

Patient safety implications of wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations.

February 15, 2023

Reducing falls with a safety spotter program.

October 14, 2015

Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port.

January 25, 2006

Medication reconciliation in the emergency department: opportunities for workflow redesign.

December 15, 2010

Creating an improvement culture for enhanced patient safety: service improvement learning in pre-registration education.

November 3, 2010

Case study: preventing surgical complications at Baystate Medical Center.

November 21, 2007

Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports.

June 7, 2017

Inter-professional clinical handover in post-anaesthetic care units: tools to improve quality and safety.

October 5, 2016

How radiation oncologists would disclose errors: results of a survey of radiation oncologists and trainees.

June 13, 2012

How patients can improve the accuracy of their medical records.

November 5, 2014

Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge.

January 7, 2015

Coworker abuse in healthcare: voices of mistreated workers.

March 15, 2023

Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research.

January 28, 2009

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

March 30, 2011

Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience.

November 28, 2007

Hospital workload and adverse events.

May 9, 2007

The role of housestaff in implementing medication reconciliation on admission at an academic medical center.

June 16, 2010

ICU nurses' acceptance of electronic health records.

July 13, 2011

Measuring inappropriate medical diagnosis and treatment in survey data: the case of ADHD among school-age children.

February 23, 2011

Fatigue risk management: the impact of anesthesiology residents' work schedules on job performance and a review of potential countermeasures.

December 13, 2017

Often overlooked problems with handoffs: from the intensive care unit to the operating room.

May 14, 2014

A critical appraisal of AHRQ's "Diagnostic Errors" report.

May 10, 2023

Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States.

May 3, 2023

Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports.

April 1, 2020

Information loss in emergency medical services handover of trauma patients.

September 23, 2009

Understanding nurses' and physicians' fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors?

September 16, 2015

Racial bias among emergency providers: strategies to mitigate its adverse effects.

May 26, 2021

Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department.

May 31, 2023

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children.

June 30, 2021

A radiation oncology-specific automated trigger indicator tool for high-risk near-miss safety events.

March 4, 2020

Consumer perceptions of safety in hospitals.

April 12, 2006

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Detection and prevention of medication errors using real-time bedside nurse charting.

August 31, 2005

Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central venous catheters from hospitals in the Prevention Epicenter Program.

January 18, 2006

Quality measures of clinical pharmacy services during transitions of care.

June 1, 2021

Advance care planning documentation practices and accessibility in the electronic health record: implications for patient safety.

March 28, 2018

Nurse staffing, burnout, and health care-associated infection.

August 15, 2012

Handoff practices in undergraduate medical education.

March 12, 2014

Modifications to medical emergency team activation criteria and implications for patient safety: a point prevalence study.

March 24, 2021

Computerized surveillance of adverse drug events in hospital patients.

March 27, 2005

Harms from discharge to primary care: mixed methods analysis of incident reports.

December 16, 2015

The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.

March 16, 2011

Patient and physician experience with interhospital transfer: a qualitative study.

May 29, 2019

Improving measurement in clinical handover.

August 19, 2009

Gaps in ambulatory patient safety for immunosuppressive specialty medications.

June 12, 2019

Eight years of decreased methicillin-resistant Staphylococcus aureus health care–associated infections associated with a Veterans Affairs prevention initiative.

February 22, 2017

Reducing prescribing errors in hospitalized children on the ketogenic diet.

February 24, 2021

Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting.

April 8, 2020

Risk factors for adverse drug events: a 10-year analysis.

June 8, 2005

One system's journey in creating a disclosure and apology program.

October 7, 2009

Measuring adverse events in hospitalized patients: an administrative method for measuring harm.

September 7, 2016

Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents.

June 6, 2012

Comparative safety of endovascular aortic aneurysm repair over open repair using Patient Safety Indicators during adoption.

July 23, 2014

National Quality Forum 30 safe practices: priority and progress in Iowa hospitals.

April 26, 2006

Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality.

March 27, 2005

An improvement approach to integrate teaching teams in the reporting of safety events.

May 10, 2017

Learning accountability for patient outcomes.

July 21, 2010

We need leaders: the 48th Annual Rovenstine Lecture.

May 19, 2010

Enhancing physicians' use of clinical guidelines.

January 8, 2014

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

What do parents think about the quality and safety of care provided by hospitals to children and young people with an intellectual disability? A qualitative study using thematic analysis.

February 7, 2024

Perspective

Patient Safety in Office-Based Care Settings

January 31, 2024

Interview

In Conversation with...Richard Ricciardi about Office-Based Patient Safety

January 31, 2024

Patient Safety Innovations

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

January 31, 2024

Parents' understanding of medication at discharge and potential harm in children with medical complexity.

December 20, 2023

Pediatric Diagnostic Safety: State of the Science and Future Directions.

September 13, 2023

In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.

September 6, 2023

Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.

August 9, 2023

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions.

March 8, 2023

Measuring psychological safety and local learning to enable high reliability organisational change.

November 9, 2022

Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality.

April 20, 2022

March 16, 2022

Inequities in quality and safety outcomes for hospitalized children with intellectual disability.

March 16, 2022

Safety, Equity and Engagement in Maternity Services.

January 12, 2022

Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study.

November 24, 2021

Apparent cause analysis: a safety tool.

May 20, 2020

Analysis of paediatric long-term ventilation incidents in the community

January 22, 2020

Pediatric clinician perspectives on communicating diagnostic uncertainty.

August 7, 2019

Perceptions of pediatric hospital safety culture in the United States: an analysis of the 2016 Hospital Survey on Patient Safety Culture.

April 24, 2019

Exploring the human factors of prescribing errors in paediatric intensive care units.

March 27, 2019

Priorities for pediatric patient safety research.

February 13, 2019

Case-based simulation empowering pediatric residents to communicate about diagnostic uncertainty.

January 16, 2019

The association of the nurse work environment and patient safety in pediatric acute care.

January 16, 2019

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.

December 19, 2018

Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children.

December 19, 2018

Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative.

December 12, 2018

Identifying electronic health record usability and safety challenges in pediatric settings.

November 28, 2018

See More About The Topic

Children's Hospitals

Health Care Executives and Administrators

Pediatrics

Epidemiology of Errors and Adverse Events

Error Reporting and Analysis

Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site