Study Anatomy of a patient safety event: a pediatric patient safety taxonomy. Citation Text: Woods DM, Johnson JK, Holl JL, et al. Anatomy of a patient safety event: a pediatric patient safety taxonomy. Qual Saf Health Care. 2005;14(6):422-7. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL December 21, 2005 Woods DM, Johnson JK, Holl JL, et al. Qual Saf Health Care. 2005;14(6):422-7. View more articles from the same authors. The authors developed a patient safety taxonomy for pediatric research and clinical practice improvement, organizing information into four key categories: problem type, medical domain, contributing factors, and event outcome. PubMed citation Available at Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Woods DM, Johnson JK, Holl JL, et al. Anatomy of a patient safety event: a pediatric patient safety taxonomy. Qual Saf Health Care. 2005;14(6):422-7. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022 The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018 Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021 Optimizing Pediatric Patient Safety in the Emergency Care Setting. October 19, 2022 Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative. May 15, 2019 Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. April 30, 2008 Association between surgeon technical skills and patient outcomes. September 9, 2020 Patient safety problems in adolescent medical care. January 18, 2006 Families as partners in hospital error and adverse event surveillance. March 8, 2017 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020 Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022 Gaps in pediatric clinician communication and opportunities for improvement. October 22, 2008 A randomized trial of a multifactorial strategy to prevent serious fall injuries. July 29, 2020 Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017 Changes in medical errors after implementation of a handoff program. November 12, 2014 Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018 Ambulatory care adverse events and preventable adverse events leading to a hospital admission. April 18, 2007 Adverse events and preventable adverse events in children. March 6, 2005 Association of patient and family reports of hospital safety climate with language proficiency in the US. June 29, 2022 Development of an emergency department trigger tool using a systematic search and modified Delphi process. July 13, 2016 The relationships among work stress, strain and self-reported errors in UK community pharmacy. March 19, 2014 Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. December 6, 2006 Incidence and types of adverse events and negligent care in Utah and Colorado. March 27, 2005 Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. July 29, 2009 Trends and patterns in reporting of patient safety situations in transplantation. February 10, 2016 Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator. July 8, 2009 Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients. August 20, 2008 Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers. April 17, 2019 Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. February 23, 2011 Establishing a simulation center for surgical skills: what to do and how to do it. September 12, 2007 An educational and audit tool to reduce prescribing error in intensive care. October 29, 2008 The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. February 10, 2021 Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems. August 1, 2012 Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023 Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 6, 2013 Response of practicing chiropractors during the early phase of the COVID-19 pandemic: a descriptive report. July 8, 2020 Description and evaluation of an interprofessional patient safety course for health professions and related sciences students. January 10, 2007 Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. March 18, 2015 Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023 Variation in caregiver perceptions of teamwork climate in labor and delivery units. July 5, 2006 The natural history of recovery for the healthcare provider "second victim" after adverse patient events. October 21, 2009 Observation for assessment of clinician performance: a narrative review. November 11, 2015 Improving handoffs in the emergency department. October 28, 2009 Errors during the preparation of drug infusions: a randomized controlled trial. August 22, 2012 Primary care pediatricians' interest in diagnostic error reduction. July 20, 2016 Diagnostic errors in primary care pediatrics: Project RedDE. November 29, 2017 Racial differences in antibiotic prescribing by primary care pediatricians. March 20, 2013 Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention. December 16, 2009 Readiness of US general surgery residents for independent practice. October 4, 2017 Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. October 27, 2021 Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. May 25, 2016 Preventability and causes of readmissions in a national cohort of general medicine patients. May 4, 2016 Medication errors in paediatric outpatients. September 8, 2010 Using a network organisational architecture to support the development of Learning Healthcare Systems. February 21, 2018 A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. March 26, 2014 Preventing home medication administration errors. March 14, 2022 A randomized trial of electronic clinical reminders to improve medication laboratory monitoring. July 23, 2008 The culture of safety: results of an organization-wide survey in 15 California hospitals. March 6, 2005 Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). June 26, 2019 Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? April 5, 2006 Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients. April 22, 2009 The cost of pneumonia after acute stroke. June 13, 2007 Developing an action plan for patient radiation safety in adult cardiovascular medicine. April 11, 2012 A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures. March 4, 2009 A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings. October 4, 2023 Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions. March 10, 2010 Reasons for after-hours calls by hospital floor nurses to on-call physicians. May 30, 2007 Development, implementation, and dissemination of the I-PASS Handoff Curriculum: a multisite educational intervention to improve patient handoffs. June 25, 2014 Complexity and challenges of the clinical diagnosis and management of Long COVID. November 30, 2022 Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. December 19, 2007 I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources. March 10, 2019 I-PASS mentored implementation handoff curriculum: champion training materials. March 13, 2019 Preventable errors in organ transplantation: an emerging patient safety issue? July 11, 2012 Disclosing harmful mammography errors to patients. December 16, 2009 Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. January 30, 2005 The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose. February 14, 2018 Recommendations to improve the usability of drug–drug interaction clinical decision support alerts. November 25, 2015 Organisational culture: variation across hospitals and connection to patient safety climate. January 5, 2011 Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009--2014. September 27, 2017 Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. March 27, 2005 Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. December 2, 2020 Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. September 2, 2020 Reducing prescribing errors in hospitalized children on the ketogenic diet. February 24, 2021 Ticket to ride: reducing handoff risk during hospital patient transport. September 10, 2008 Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011 A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. February 2, 2011 Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers. September 23, 2020 Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability. November 22, 2006 A national mixed-methods evaluation of preparedness for general surgery residency and the association with resident burnout. September 2, 2020 High-alert medications in the pediatric intensive care unit. January 7, 2009 Prospective study of the multisite spread of a medication safety intervention: factors common to hospitals with improved outcomes. February 7, 2024 Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial. November 15, 2023 We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021 Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023 Teamwork on inpatient medical units: assessing attitudes and barriers. May 5, 2010 How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. September 7, 2005 National Patient Safety Foundation agenda for research and development in patient safety. March 27, 2005 Description and yield of current quality and safety review in selected US academic emergency departments. August 30, 2017 Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation. September 16, 2020 A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. February 11, 2009 View More Related Resources Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system. May 1, 2024 Annual Perspective Equity in Patient Safety March 27, 2024 Classification of health information technology safety events in a pediatric tertiary care hospital. June 7, 2023 Annual Perspective Improving Diagnostic Safety and Quality April 26, 2023 Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions. March 8, 2023 Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients. March 2, 2022 A quality improvement initiative to improve patient safety event reporting by residents. February 9, 2022 Differences in safety report event types submitted by graduate medical education trainees compared with other healthcare team members. December 8, 2021 Patient Safety Innovations Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors September 29, 2021 Healthcare worker serious safety events: applying concepts from patient safety to improve healthcare worker safety. August 4, 2021 Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri. February 10, 2021 Increasing physician reporting of diagnostic learning opportunities. December 23, 2020 Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals. October 14, 2020 Pediatric clinician comfort discussing diagnostic errors for improving patient safety: a survey. April 22, 2020 Encouraging resident adverse event reporting: a qualitative study of suggestions from the front lines. October 30, 2019 Patient safety morning report: innovation in teaching core patient safety principles to third-year medical students. July 10, 2019 A quality improvement initiative to reduce safety events among adolescents hospitalized after a suicide attempt. May 15, 2019 Exploring the human factors of prescribing errors in paediatric intensive care units. March 27, 2019 Closing the disclosure gap: medical errors in pediatrics. March 27, 2019 Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. February 6, 2019 What is new in paediatric medication safety? September 12, 2018 Outpatient opioid prescriptions for children and opioid-related adverse events. August 8, 2018 10,000 good catches: increasing safety event reporting in a pediatric health care system. June 27, 2018 Report faults Children's Hospital for medication errors. June 6, 2018 Pediatric ADHD medication exposures reported to US poison control centers. June 6, 2018 Iatrogenesis in Pediatrics. September 20, 2017 The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation. September 13, 2017 Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attribution theory perspective. August 30, 2017 Why it is so hard to talk about overuse in pediatrics and why it matters. August 30, 2017 Deployment of a second victim peer support program: a replication study. August 16, 2017 View More See More About The Topic Children's Hospitals Ambulatory Care Risk Managers Quality and Safety Professionals Pediatrics View More
Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022
The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018
Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021
Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative. May 15, 2019
Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. April 30, 2008
Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018
Ambulatory care adverse events and preventable adverse events leading to a hospital admission. April 18, 2007
Association of patient and family reports of hospital safety climate with language proficiency in the US. June 29, 2022
Development of an emergency department trigger tool using a systematic search and modified Delphi process. July 13, 2016
The relationships among work stress, strain and self-reported errors in UK community pharmacy. March 19, 2014
Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. December 6, 2006
Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. July 29, 2009
Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator. July 8, 2009
Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients. August 20, 2008
Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers. April 17, 2019
Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. February 23, 2011
Establishing a simulation center for surgical skills: what to do and how to do it. September 12, 2007
The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. February 10, 2021
Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems. August 1, 2012
Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 6, 2013
Response of practicing chiropractors during the early phase of the COVID-19 pandemic: a descriptive report. July 8, 2020
Description and evaluation of an interprofessional patient safety course for health professions and related sciences students. January 10, 2007
Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. March 18, 2015
Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023
The natural history of recovery for the healthcare provider "second victim" after adverse patient events. October 21, 2009
Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention. December 16, 2009
Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. October 27, 2021
Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. May 25, 2016
Preventability and causes of readmissions in a national cohort of general medicine patients. May 4, 2016
Using a network organisational architecture to support the development of Learning Healthcare Systems. February 21, 2018
A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. March 26, 2014
A randomized trial of electronic clinical reminders to improve medication laboratory monitoring. July 23, 2008
The culture of safety: results of an organization-wide survey in 15 California hospitals. March 6, 2005
Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). June 26, 2019
Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? April 5, 2006
Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients. April 22, 2009
Developing an action plan for patient radiation safety in adult cardiovascular medicine. April 11, 2012
A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures. March 4, 2009
A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings. October 4, 2023
Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions. March 10, 2010
Development, implementation, and dissemination of the I-PASS Handoff Curriculum: a multisite educational intervention to improve patient handoffs. June 25, 2014
Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. December 19, 2007
I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources. March 10, 2019
Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. January 30, 2005
The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose. February 14, 2018
Recommendations to improve the usability of drug–drug interaction clinical decision support alerts. November 25, 2015
Organisational culture: variation across hospitals and connection to patient safety climate. January 5, 2011
Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009--2014. September 27, 2017
Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. March 27, 2005
Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. December 2, 2020
Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. September 2, 2020
Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011
A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. February 2, 2011
Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers. September 23, 2020
Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability. November 22, 2006
A national mixed-methods evaluation of preparedness for general surgery residency and the association with resident burnout. September 2, 2020
Prospective study of the multisite spread of a medication safety intervention: factors common to hospitals with improved outcomes. February 7, 2024
Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial. November 15, 2023
We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021
How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. September 7, 2005
National Patient Safety Foundation agenda for research and development in patient safety. March 27, 2005
Description and yield of current quality and safety review in selected US academic emergency departments. August 30, 2017
Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation. September 16, 2020
A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. February 11, 2009
Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system. May 1, 2024
Classification of health information technology safety events in a pediatric tertiary care hospital. June 7, 2023
Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions. March 8, 2023
Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients. March 2, 2022
A quality improvement initiative to improve patient safety event reporting by residents. February 9, 2022
Differences in safety report event types submitted by graduate medical education trainees compared with other healthcare team members. December 8, 2021
Patient Safety Innovations Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors September 29, 2021
Healthcare worker serious safety events: applying concepts from patient safety to improve healthcare worker safety. August 4, 2021
Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri. February 10, 2021
Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals. October 14, 2020
Pediatric clinician comfort discussing diagnostic errors for improving patient safety: a survey. April 22, 2020
Encouraging resident adverse event reporting: a qualitative study of suggestions from the front lines. October 30, 2019
Patient safety morning report: innovation in teaching core patient safety principles to third-year medical students. July 10, 2019
A quality improvement initiative to reduce safety events among adolescents hospitalized after a suicide attempt. May 15, 2019
Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. February 6, 2019
10,000 good catches: increasing safety event reporting in a pediatric health care system. June 27, 2018
The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation. September 13, 2017
Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attribution theory perspective. August 30, 2017