The incidence and types of adverse events can vary widely across different clinical settings. This retrospective cohort study used a novel trigger tool to classify adverse events in the pediatric intensive care unit, with a particular focus on medication errors and patient-level risk factors for errors. The overall incidence of errors was similar to that found in prior studies, with surgical patients and intubated patients being most vulnerable to error. Medication errors were the most common type of error in this study, and prior research in the pediatric ICU setting has documented the benefit of computerized provider order entry for preventing medication prescribing errors, an example of which is discussed in an AHRQ WebM&M commentary.

This study of nursing handoffs found frequent errors in communication of clinical information and medication reconciliation when patients were transferred from the pediatric intensive care unit to the general ward.

… issues contributing to errors in a pediatric population. … Larsen GY, Donaldson AE, Parker HB, Grant MJ. Preventable harm occurring to critically ill …

The authors describe a paper-based reporting initiative that effectively captured adverse event and near miss data and provided important information about patient safety issues frequently encountered by frontline clinicians.

… of teamwork and safety culture in a children's hospital. … Grant MJ, Donaldson AE, Larsen GY. The safety culture in a children's hospital.  J …

This study evaluated the impact of three independent medication safety interventions on the incidence of reported infusion errors. Investigators collected data before and after the interventions and discovered a 73% reduction in reported errors. The authors conclude that implementation of new technology in conjunction with simple system changes provides opportunities to improve the safety of care in an increasingly complex health care environment.