Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system.

K. L. Dunn; P. Reddy; A. Moulden; G. Bowes

Study

Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system.

November 9, 2005

Dunn KL, Reddy P, Moulden A, et al. Arch Dis Child. 2006;91(2):169-72.

View more articles from the same authors.

The investigators reviewed pediatric admissions over a 6-year period and analyzed detected adverse events. The authors determined that continuous medical record review is useful in driving quality improvement strategies.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

In the wake of hospital inquiries: impact on staff and safety.

January 31, 2007

A piece of my mind. Coping with fallibility.

March 6, 2005

A systematic review of interventions to follow-up test results pending at discharge.

February 7, 2018

The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre.

April 15, 2009

The economic consequences of medical injuries: implications for a no-fault insurance plan.

March 6, 2005

The heart of darkness: the impact of perceived mistakes on physicians.

March 6, 2005

Critical phase distractions in anaesthesia and the sterile cockpit concept.

March 30, 2011

Attitudes and barriers to a medical emergency team system at a tertiary paediatric hospital.

January 5, 2011

Investigating patient safety culture across a health system: multilevel modelling of differences associated with service types and staff demographics.

July 25, 2012

Medical team training: applying crew resource management in the Veterans Health Administration.

May 30, 2007

SBAR improves nurse–physician communication and reduces unexpected death: a pre and post intervention study.

October 23, 2013

Examining the validity of AHRQ's Patient Safety Indicators (PSIs): is variation in PSI composite score related to hospital organizational factors?

November 26, 2014

Recommendations from a national panel on quality improvement in obstetrics.

April 24, 2019

The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II.

March 27, 2005

Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors.

April 21, 2010

Measuring hospital-acquired complications associated with low-value care.

March 6, 2019

Surgical site verification: A through Z.

November 22, 2006

Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors.

April 8, 2015

Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient.

February 2, 2022

Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?

October 27, 2010

Overestimation of clinical diagnostic performance caused by low necropsy rates.

December 14, 2005

Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System.

February 25, 2009

The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre.

April 22, 2009

Teamwork and error in the operating room: analysis of skills and roles.

April 23, 2008

Teaching quality improvement and patient safety in residency education: strategies for meaningful resident quality and safety initiatives.

August 23, 2017

Patient safety systems in the primary health care of diabetes—a story of missed opportunities?

November 17, 2010

Distraction and interruption in anaesthetic practice.

January 23, 2013

Identification of in-hospital complications from claims data. Is it valid?

March 6, 2005

Global oximetry: an international anaesthesia quality improvement project.

October 21, 2009

Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada.

April 3, 2024

Incorrect surgical procedures within and outside of the operating room.

November 25, 2009

Reducing adverse drug events: lessons from a breakthrough series collaborative.

March 27, 2005

Double reading in breast cancer screening: cohort evaluation in the CO-OPS trial.

August 29, 2018

Use of cellular telephones in the hospital environment.

March 28, 2007

Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation.

April 1, 2020

Implementation and spread of a simple and effective way to improve the accuracy of medicines reconciliation on discharge: a hospital-based quality improvement project and success story.

September 11, 2019

Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation.

May 15, 2013

How can the principles of complexity science be applied to improve the coordination of care for complex pediatric patients?

April 19, 2006

Factors influencing incident reporting in surgical care.

April 22, 2009

A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.

November 28, 2012

Novel analysis of clinically relevant diagnostic errors in point-of-care devices.

October 19, 2011

Patient risk factors for medical injury: a case–control study.

January 26, 2011

Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research Network.

November 17, 2010

Developing and implementing new safe practices: voluntary adoption through statewide collaboratives.

August 16, 2006

A preliminary taxonomy of medical errors in family practice.

March 6, 2005

Problem list completeness in electronic health records: a multi-site study and assessment of success factors.

August 26, 2015

Association between day of delivery and obstetric outcomes: observational study.

December 9, 2015

Side errors in neurosurgery.

November 15, 2006

Comparing measures of patient safety for inpatient care provided to veterans within and outside the VA system in New York.

February 27, 2008

The impact of shift patterns on junior doctors' perceptions of fatigue, training, work/life balance and the role of social support.

December 22, 2010

Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit.

November 8, 2006

Enhancing medication use safety: benefits of learning from your peers.

October 21, 2009

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

February 17, 2010

Motivational influences on anaesthetists' use of practice guidelines.

May 13, 2009

Inter-rater reliability of a classification system for hospital adverse drug event reports.

September 12, 2007

Learning from malpractice claims about negligent, adverse events in primary care in the United States.

March 6, 2005

Resident fatigue: is there a patient safety issue?

January 6, 2010

Development and measurement of perioperative patient safety indicators.

March 18, 2015

What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.

May 5, 2010

Lessons learned from implementation of a computerized application for pending tests at hospital discharge.

December 22, 2010

Potential role of pharmacogenomics in reducing adverse drug reactions: a systematic review.

August 31, 2005

Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial.

July 15, 2020

Effect on patient safety of a resident physician schedule without 24-hour shifts.

July 15, 2020

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

May 26, 2010

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

Human factors in anaesthesia: a narrative review.

February 15, 2023

Relationship between systems-level factors and hand hygiene adherence.

June 9, 2010

Improving measurement in clinical handover.

August 19, 2009

Unrecognized cardiovascular emergencies among Medicare patients.

March 14, 2018

Effect of outcome on physician judgments of appropriateness of care.

March 6, 2005

Care and outcomes of patients with in-hospital stroke.

June 17, 2015

Nurse workarounds in the electronic health record: an integrative review.

August 12, 2020

Follow-up of outpatient test results: a survey of house-staff practices and perceptions.

May 24, 2006

Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors.

April 9, 2008

When a vital sign leads a country astray—the opioid epidemic.

September 4, 2019

The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics.

October 29, 2008

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).

June 26, 2019

The high cost of low-frequency events: the anatomy and economics of surgical mishaps.

March 27, 2005

Extended work shifts and neurobehavioral performance in resident-physicians.

March 10, 2021

Improving medication-related clinical decision support.

March 7, 2018

Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory.

December 3, 2008

Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study.

April 26, 2023

Does increased schedule flexibility lead to change? A national survey of program directors on 2017 work hours requirements.

September 23, 2020

Developing a standard handoff process for operating room–to-ICU transitions: multidisciplinary clinician perspectives from the Handoffs and Transitions in Critical Care (HATRICC) study.

August 1, 2018

The relationship between professional burnout and quality and safety in healthcare: a meta-analysis.

April 19, 2017

Human factors engineering in healthcare systems: the problem of human error and accident management.

January 21, 2009

Active surveillance using electronic triggers to detect adverse events in hospitalized patients.

June 14, 2006

Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.

March 6, 2013

Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.

January 7, 2009

Resident participation does not affect surgical outcomes, despite introduction of new techniques.

September 22, 2010

Introducing the patient safety professional: why, what, who, how, and where?

September 28, 2011

Role of registered nurses in error prevention, discovery and correction.

April 16, 2008

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

October 21, 2009

First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes.

October 31, 2012

Fatal errors in nitrous oxide delivery.

January 2, 2008

A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study.

February 6, 2019

Iatrogenic delirium and coma: a "near miss."

May 21, 2008

Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school.

January 20, 2021

Establishing a simulation center for surgical skills: what to do and how to do it.

September 12, 2007

Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation.

May 20, 2015

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals.

February 28, 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

Racial and ethnic disparities in common inpatient safety outcomes in a children's hospital cohort.

August 16, 2023

Opportunities for diagnostic improvement among pediatric hospital readmissions.

June 28, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

STAMP: a 5-year project to reduce paediatric prescribing errors.

April 19, 2023

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.

January 18, 2023

Patient Safety Innovations

Journal Article

Study

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

November 16, 2022

Experience of learning from everyday work in daily safety huddles: a multi-method study.

September 14, 2022

Reported clinical incidents of children with intellectual disability: a qualitative analysis.

June 15, 2022

March 16, 2022

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

March 16, 2022

Improving hospital infant safe sleep compliance by using safety prevention bundle methodology.

February 2, 2022

Where trust flourishes: perceptions of clinicians who trust their organizations and are trusted by their patients.

January 12, 2022

Racism as a Root Cause approach: a new framework.

January 1, 2021

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.

August 26, 2020

Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study.

July 22, 2020

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

January 29, 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

Reclaiming the systems approach to paediatric safety.

April 10, 2019

Priorities for pediatric patient safety research.

February 13, 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

The prevalence of dose errors among paediatric patients in hospital wards with and without health information technology: a systematic review and meta-analysis.

October 24, 2018

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

September 26, 2018

Improving pediatric electronic health record usability and safety through certification: seize the day.

September 26, 2018

See More About The Topic

Children's Hospitals

Health Care Providers

Health Care Executives and Administrators

Pediatrics

Epidemiology of Errors and Adverse Events

Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system.

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

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system.

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

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

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