Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "United States of America"

1 - 13 of 13 results
Download Selected Citations

Show: 20 | 50 | 100

Journal Article > Commentary

Why studying human behavior is a critical component of patient safety.

Su L. Curr Probl Pediatr Adolesc Health Care. 2015;45:367-369.

Efforts to understand the nature of human error can enhance care safety. Discussing the potential for unexpected human behaviors during crises to result in failure, this commentary reveals how insights drawn from video analysis of teams in critical situations informed adjustments to training to reduce risks in cardiac care.

Journal Article > Study

Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.

Bowermaster R, Miller M, Ashcraft T, et al. J Am Coll Surg. 2015;220:149–155.e3.

This observational study describes how a pediatric cardiac surgery team used the human factors approach of recording even small deviations from ideal practice in order to better characterize safety problems. The authors describe how systematically capturing small failures led to recognition of faulty processes that could be addressed. A recent AHRQ WebM&M commentary discusses the application of human factors engineering to enhance safety of medical device design.

Journal Article > Study

Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest.

Lammers RL, Willoughby-Byrwa M, Fales WD. Simul Healthc. 2014;9:174-183.

Simulations of prehospital pediatric cardiopulmonary arrest uncovered many potential errors. Most notably, medication errors related to the correct weight-based dosing of epinephrine were common. This mistake can have serious consequences and warrants further efforts to mitigate this risk.

Journal Article > Study

Accuracy of interpretation of preparticipation screening electrocardiograms.

Hill AC, Miyake CY, Grady S, Dubin AM. J Pediatr. 2011;159:783-788.

Controversy exists regarding whether children should be required to undergo an electrocardiogram before participating in competitive sports. This study found a significant rate of diagnostic error among pediatric cardiologists in the interpretation of abnormal screening electrocardiograms.

Journal Article > Study

Retrospective review of emergency response activations during a 13-year period at a tertiary care children's hospital.

Wang GS, Erwin N, Zuk J, Henry DB, Dobyns EL. J Hosp Med. 2011;6:131-135.

This study found that 39% of emergency response activations occurred in children younger than age 1 year, with the most common admission diagnosis related to cardiac disease. The authors suggest that young children with known comorbidities may benefit from more deliberate patient planning, placement, staffing, and early ICU intervention.

Journal Article > Study

A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system.

Hanson CC, Randolph GD, Erickson JA, et al. Qual Saf Health Care. 2009;18:500-504.

The effect of rapid response systems on clinical outcomes in adult patients remains controversial, but prior studies in children's hospitals have shown a significant benefit. This pediatric study found fewer cardiac arrests after implementing a rapid response team (RRT) consisting of a critical care physician, nurse, and respiratory therapist. Presence of the RRT also resulted in unstable patients being evaluated more promptly; earlier evaluation has been correlated with improved outcomes in prior studies. Though not formally requiring a rapid response system, The Joint Commission does require that all hospitals maintain a system for rapid evaluation of unstable patients as one of the National Patient Safety Goals.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.

Journal Article > Study

Nurses' perceptions of subspecialization in pediatric cardiac intensive care unit: quality and patient safety implications.

Kane JM, Preze E. J Nurs Care Qual. 2009;24:354-361. 

Creation of a dedicated pediatric cardiac surgery unit was felt to have clinical benefits, but many nurses reported feeling unable to provide safe care due to inadequate training or experience. The Bristol Royal Infirmary pediatric cardiology unit is considered a classic case of how a dysfunctional organization can result in dire clinical consequences.

Journal Article > Study

Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests.

Hunt EA, Vera K, Diener-West M, et al. Resuscitation. 2009;80:819-825.

This study found that pediatric residents failed to consistently perform cardiopulmonary resuscitation according to established guidelines, mirroring results from a prior study in adult patients.

Journal Article > Study

Missed diagnosis of critical congenital heart disease.

Chang RK, Gurvitz M, Rodriguez S. Arch Pediatr Adolesc Med. 2008;162:969-974.

This population-based study revealed that approximately 30 infants per year in California die due to missed diagnoses of congenital heart disease. Screening for specific disorders should be performed at the first postdischarge pediatrician visit.

Journal Article > Study

Diagnostic errors in pediatric echocardiography: development of taxonomy and identification of risk factors.

Benavidez OJ, Gauvreau K, Jenkins KJ, Geva T. Circulation. 2008;117:2995-3001.

Diagnostic errors in pediatric echocardiography were infrequent, but generally were severe enough to change patient management, and were mostly considered preventable.

Journal Article > Study

Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams.

Bognár A, Barach P, Johnson JK, et al. Ann Thorac Surg. 2008;85:1374-1381.

In this study, researchers evaluated the culture of safety in pediatric cardiac surgery teams by using a survey based on the Safety Attitudes Questionnaire. Overall, teamwork was rated relatively low, similar to prior research analyzing operating room safety culture.

Journal Article > Study

Underdiagnosis of hypertension in children and adolescents.

Hansen ML, Gunn PW, Kaelber DC. JAMA. 2007;298:874-879.

In this study, only one-quarter of children with high blood pressure were correctly diagnosed with hypertension. The authors attribute this to two factors: pediatricians' lack of knowledge of the normal blood pressure range for different ages and lack of awareness of patients' previous blood pressure measurements.

Back to Top