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- Pediatric Surgery
Grant T. Washington Post. July 22, 2008:HE01
This article reports on a wrong-sided surgery near miss from the perspective of a parent, and discusses the role of family members in preventing medical errors.
Web Resource > Multi-use Website
Food and Drug Administration and the International Anesthesia Research Society.
This Web site hosts advice, news, events, and interviews related to anesthetic medication safety for pediatric patients.
Luby R. KETV. Omaha, NE. March 31, 2010.
This news piece focuses on a heparin overdose that resulted in the death of a toddler.
Kowalczyk L. Boston Globe. April 17, 2009;Metro:1.
This newspaper article discusses one hospital's decision to temporarily close its pediatric cardiac surgery program following errors that caused serious complications for two infants.
Journal Article > Study
Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes?
Sobo EJ. Soc Sci Med. 2005;60:2341-2350.
This study described findings from 35 interviews with parents about perceptions of error risk during their child's surgery. Through qualitative analysis, the investigators identified 12 themes from the interview transcripts. The themes were divided into "worries or fears" and "reassuring considerations," with detailed examples of each provided in the discussion. Strategies to address the patient-centered approach are offered along with their relation to risk management goals. The authors conclude that understanding parents' expectations and vulnerability plays an essential role when communicating risks in these settings.
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.
London, England: The Stationery Office; July 2001.
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.