Children undergoing intrahospital transport are at risk for adverse events. This study used perioperative adverse event data reported to a patient safety organization to identify pediatric anesthesia transport-associated adverse events. A small proportion (5%) of pediatric anesthesia adverse events were associated with transport, but the majority of events were deemed preventable and one-third resulted in patient harm. Cardiac arrest and respiratory events occurred most frequently and largely affected very young children (<6 month). A previous WebM&M discussed a perioperative respiratory event in a pediatric patient during intrahospital transport.

This systematic review was undertaken to provide clear enumeration of adverse events that have occurred during intrahospital transport of critically ill children, risk factors for those events, and guidance for event prevention to clinicians who may not be fully aware of the risks of transport. The recommendations for reducing adverse events frequently given in the 40 articles that met the inclusion criteria (reflecting 4104 children transported) included: use of checklists and improved double-checks (of, e.g., equipment before transport).

… , potential budget challenges, and disclosure as a standard of care. … A. … Z. … Hendrich … Haydar … A. Hendrich … Z. Haydar …

… guidelines for urinary catheter placement led by a clinician champion in emergency departments decreased …

… disclosure of medical errors has been described as both a great idea and an impractical risk management strategy. … case study evaluated Ascension Health's implementation of a full disclosure protocol during a 2-year period and found that staff support and compliance …

… … Articles in this special issue cover findings from a federally-funded initiative to identify approaches to … strategies. … JM … MJ … L. … WM … SK … TH … EJ … A. … CK … J. … L. … P. … JK … A. … A. … M. … LM … J. … MM … … … Ottosen … Burress … Sage … Bell … Gallagher … Thomas … Hendrich … McCoy … Gale … Sparkman … Santos … Iglehart … …

… reliability organizations can improve safety. … Pryor D, Hendrich A, Henkel RJ, Beckmann JK, Tersigni AR. The quality 'journey' … how we've prevented at least 1,500 avoidable deaths a year--and aim to do even better.  Health Aff (Millwood) . …

This project summary articulates the associations between the Joint Commission National Patient Safety Goals and patient outcomes. The piece includes charts that clearly summarize the evidence and practice guidelines for these safety goals.

The authors share initial data from a system-wide effort to improve safety and quality in their hospitals by 2008.