Managing the adverse event occurring during elective, ambulatory pediatric surgery.

Erik D. Skarsgard

Commentary

Managing the adverse event occurring during elective, ambulatory pediatric surgery.

May 20, 2009

Skarsgard ED. Semin Pediatr Surg. 2009;18(2):122-4.

View more articles from the same authors.

This case study addresses the complexities of disclosing adverse events affecting children. The article provides a framework of potential steps for health care professionals to take after a medical error occurs.

PubMed citation

Available at

Related Resources From the Same Author(s)

Is safety a subject for science?

September 11, 2013

Interruptions in clinical nursing practice.

November 6, 2013

Resilience and resilience engineering in health care.

July 30, 2014

A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.

April 27, 2005

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

July 14, 2010

The challenge of risk prevention in home healthcare-an interview study with nurses in municipal care.

July 12, 2023

Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety.

March 26, 2014

Practice gaps in patient safety among dermatology residents and their teachers: a survey study of dermatology residents.

April 23, 2014

The emotional impact of medical errors on practicing physicians in the United States and Canada.

August 1, 2007

Medical teamwork and the evolution of safety science: a critical review.

March 11, 2020

Explaining the unexplainable—the impact of physicians' attitude towards litigation on their incident disclosure behaviour.

January 7, 2015

Association of a Safety Program for Improving Antibiotic Use with antibiotic use and hospital-onset Clostridioides difficile infection rates among US hospitals

March 10, 2021

“Brave men” and “emotional women”: a theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain.

February 25, 2018

Momentary interruptions can derail the train of thought.

January 30, 2013

Trends in opioid use in commercially insured and Medicare Advantage populations in 2007–16: retrospective cohort study.

August 29, 2018

Malpractice liability and health care quality: a review

February 19, 2020

Standardization and visualization of the surgical time-out.

October 4, 2023

An investigation of diagnostic accuracy and confidence associated with diagnostic checklists as well as gender biases in relation to mental disorders.

December 21, 2016

Watson: Beyond Jeopardy!

August 21, 2013

Hand-off Communications.

October 27, 2010

Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.

March 27, 2005

Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use.

October 25, 2017

'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety.

November 20, 2019

Trainees' perceptions of being allowed to fail in clinical training: a sense-making model.

December 14, 2022

'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.

November 24, 2021

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace.

March 1, 2023

Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice.

November 15, 2017

Reporting and disclosing medical errors: pediatricians' attitudes and behaviors.

February 7, 2007

Patients' willingness and ability to identify and respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data.

July 27, 2022

Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis.

July 8, 2020

ED overcrowding is associated with an increased frequency of medication errors.

March 31, 2010

Patient safety: Part II. Opportunities for improvement in patient safety.

August 19, 2009

Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care.

February 7, 2007

Long-term risk of overdose or mental health crisis after opioid dose tapering.

July 13, 2022

New persistent opioid use after postoperative intensive care in US veterans.

June 19, 2019

Enhancing safety culture through improved incident reporting: a case study in translational research.

December 12, 2018

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.

February 14, 2018

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process.

February 1, 2017

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory.

October 19, 2022

Learning from complaints in healthcare: a realist review of academic literature, policy evidence and front-line insights.

February 26, 2020

Physicians' responses to clinical decision support on an intensive care unit—comparison of four different alerting methods.

November 20, 2013

Assessment of patients' ability to review electronic health record information to identify potential errors: cross-sectional web-based survey.

March 10, 2021

Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative.

February 5, 2014

Clostridium Difficile infection in the United States: a national study assessing preventive practices used and perceptions of practice evidence.

May 20, 2015

Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment.

July 2, 2008

An estimate of missed pediatric sepsis in the emergency department.

June 2, 2021

The effect of a clinical decision support for pending laboratory results at emergency department discharge.

February 13, 2019

Use and impact of virtual primary care on quality and safety: the public's perspectives during the COVID-19 pandemic.

January 12, 2022

Adverse events in patients with return emergency department visits.

January 14, 2015

Getting the whole story: integrating patient complaints and staff reports of unsafe care.

July 28, 2021

The WHO surgical safety checklist: survey of patients' views.

August 6, 2014

Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns.

November 3, 2010

Simulation-based education enhances patient safety behaviors during central venous catheter placement.

September 15, 2021

Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study.

December 17, 2014

A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project."

August 20, 2014

Development of the pharmacy safety climate questionnaire: a principal components analysis.

March 11, 2009

Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study.

April 1, 2015

The effects of electrode misplacement on clinicians' interpretation of the standard 12-lead electrocardiogram.

November 7, 2012

Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial.

January 24, 2018

Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries.

March 3, 2021

Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency.

December 13, 2006

Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors' and managers' views.

March 6, 2005

Gaps in the continuity of care and progress on patient safety.

March 6, 2005

The public has been forgiving. But hospitals got some things wrong.

June 3, 2020

Patient safety: the patient's role.

February 14, 2007

Not again!

July 20, 2005

Facing our mistakes.

March 27, 2005

Continuous improvement as an ideal in health care.

March 27, 2005

Sentinel events. In memory of Ben—a case study.

March 27, 2005

Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.

December 20, 2006

Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses.

February 17, 2010

Role of parents in the promotion of hand hygiene in the paediatric setting: a systematic literature review.

April 6, 2016

Patient safety: disclosure of medical errors and risk mitigation.

August 3, 2016

Nurses' attitudes to a medical emergency team service in a teaching hospital.

December 20, 2006

Incident reporting system does not detect adverse drug events: a problem for quality improvement.

March 27, 2005

Applying modern error theory to the problem of missed injuries in trauma.

April 2, 2008

Development of an expert system for classification of medical errors.

June 15, 2005

Safety culture assessment in community pharmacy: development, face validity, and feasibility of the Manchester Patient Safety Assessment Framework.

December 21, 2005

Ethical challenges in child abuse: what is the harm of a misdiagnosis?

June 9, 2021

Effective approaches to control non-actionable alarms and alarm fatigue.

September 12, 2018

Semi-supervised classification of patient safety event reports.

June 6, 2012

Patient safety in obstetrics and gynecology: an agenda for the future.

November 15, 2006

Preventing pressure ulcers: the goal is zero.

October 17, 2007

A medication safety education program to reduce the risk of harm caused by medication errors.

September 5, 2007

Opioids, iatrogenic harm and disclosure of medical error.

April 7, 2010

Perspective: ten thousand hours to patient safety, sooner or later.

January 30, 2005

Simulation in obstetric anesthesia.

November 9, 2011

Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project.

February 29, 2012

Effort in human factors performance and decision making.

January 21, 2015

Medical device-associated safety and risk: surveillance and stratagems.

March 6, 2005

A hospitalization from hell: a patient's perspective on quality.

March 6, 2005

Building a learning organization.

March 27, 2005

Incidence of adverse drug events and potential adverse drug events: implications for prevention.

March 27, 2005

Human factors in anaesthetic practice: insights from a task analysis.

March 19, 2008

Impact of a standard medication chart on prescribing errors: a before-and-after audit.

December 16, 2009

How to develop a second victim support program: a toolkit for health care organizations.

May 2, 2012

An exploratory study measuring verbal order content and context.

June 10, 2009

Weekend hospitalization and additional risk of death: an analysis of inpatient data.

February 29, 2012

Cognitive aids in the management of clinical emergencies: a systematic review.

January 18, 2023

Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention.

August 22, 2018

Related Resources

Research from webAIRS incident reporting system.

November 29, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Communication matters when it comes to adverse events: associations of adverse events during implant treatment with patients' communication quality and trust assessments.

March 15, 2023

Error traps in acute pain management in children.

September 21, 2022

Trial and error: learning from malpractice claims in childhood surgery.

August 24, 2022

Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family.

June 1, 2022

WebM&M Cases

Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest

January 26, 2022

Communication regarding adverse neonatal birth events: experiences of parents and clinicians.

December 1, 2021

Pediatric medication errors and reduction strategies in the perioperative period.

November 24, 2021

Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative.

February 3, 2021

Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery.

February 3, 2021

COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected.

August 19, 2020

Communication with patients and families regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure.

August 12, 2020

Race, postoperative complications, and death in apparently healthy children.

August 12, 2020

Reimagining Healing after Healthcare Harm: The Potential for Restorative Practices.

July 29, 2020

The patient died: what about involvement in the investigation process?

June 24, 2020

What constitutes effective team communication after an error?

May 27, 2020

"Everybody makes mistakes": children's views on medical errors and disclosure.

January 29, 2020

Error disclosure and apology in radiology: the case for further dialogue.

September 25, 2019

Engaging the patient and family in the surgical safety process utilizing SafeStart.

August 28, 2019

Surgical safety checklists in children's surgery: surgeons' attitudes and review of the literature.

February 6, 2019

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

December 19, 2018

Heartbroken.

December 12, 2018

Frequency of medication error in pediatric anesthesia: a systematic review and meta-analytic estimate.

December 5, 2018

Holding out for an apology.

December 5, 2018

Quality, Value, and Patient Safety in Orthopedic Surgery.

October 24, 2018

Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events.

September 26, 2018

Safety stop: a valuable addition to the pediatric universal protocol.

September 5, 2018

Are we missing the near misses in the OR? Underreporting of safety incidents in pediatric surgery.

April 11, 2018

Enhancing pediatric perioperative patient safety.

November 29, 2017

See More About The Topic

Outpatient Surgery

Health Care Providers

Risk Managers

Quality and Safety Professionals

Pediatrics

Managing the adverse event occurring during elective, ambulatory pediatric surgery.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Managing the adverse event occurring during elective, ambulatory pediatric surgery.

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