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[Implementation of a Plan of Patient Safety in Service of Pediatric Surgery. First results]
R M Paredes Esteban1, J I Garrido Pérez1, A Ruiz Palomino1
1UGC de Cirugía Pediátrica. Hospital Reina Sofía. Córdoba.
Insights
Pediatric surgery patients experienced adverse events (AE) in 32.6% of cases, with vomiting, itching, and pain being most common. Regular audits help identify and address AE, though serious events may be missed.
Area of Science:
- Pediatric Surgery
- Patient Safety
- Healthcare Quality Improvement
Background:
- Implementation of a Patient Safety Strategic in Pediatric Surgery began in 2014.
- Focus on measuring and understanding adverse events (AE) within the department.
Purpose of the Study:
- To describe the outcomes and findings of the implemented Patient Safety Strategic.
- To analyze the prevalence and types of adverse events in pediatric surgical patients.
Main Methods:
- Utilized a modified Global Trigger Tool (GTT) from the Institute for Healthcare Improvement for AE measurement.
- Conducted monthly audits of medical records for 12 hospitalized pediatric surgery patients.
- An evaluation team comprising a pediatric surgeon, nurses, and quality department staff performed record reviews.
Main Results:
- Reviewed 95 clinical records, totaling 406 hospital stay days.
- 31 patients (32.6%) experienced at least one AE; 43 AE were identified.
- The AE rate was 105.9 per 1000 patient-days, with vomiting, itching, and pain as the most frequent.
- AEs were predominantly mild (28) or moderate (3) in severity; no serious or critical events were reported.
Conclusions:
- Regular medical record assessments provide an accessible method for tracking AE frequency and types.
- This approach facilitates the implementation of corrective measures to enhance patient safety.
- A key limitation is the potential to overlook serious AE and sentinel events occurring between assessments.
Objectives:
In 2014 our department starts to apply the PatientSafety Strategic in Pediatric Surgery. Our aim is to describe the results obtained.
Methods:
For the measurement of adverse events (AE) we used a modification of the Global Trigger Tool of the Institute for Healthcare Improvement. Population analysed: patients undergoing surgery with hospitalization. On a monthly basis, audits of the medical records of 12 patients discharged in the prior week of the assessment were performed. The evaluation team was composed by experienced pediatric surgeon, two staff nurses, and a doctor and nurse from the Quality Department.
Results:
95 clinical records and a total of 406 days of hospital stay were reviewed. 31 patients (32.6%) experienced one or more AE. Total AE: 43. The AE/1000 patients/day ratio: 105.9. The most common AE were: vomiting, itching and pain. 28 EA were considerd mild and 3 moderate in severity, according to the classification of the National Coordinating Council for Medication Error Reporting and Prevention. No EA were considered serious or critical.
Conclusions:
The analysis of prevalence through regular assessments of medical records is an easy method to obtain information about the frequency of occurrence, exact understanding of the AE types and the implementation of corrective measures. The main limitation of this method is that it can miss some of the serious EA and miss the records and analysis of sentinel events that may occur in the period between assessments.
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