Implementation of Improvements Based on the Analysis of Severe Adverse Events in Pediatric Patients

Authors

  • Cecilia T. Bigio, MD Joana de Gusmão Children’s Hospital https://orcid.org/0000-0002-7658-1839
  • Marcia R. Rodrigues Joana de Gusmão Children’s Hospital
  • Carolina de Melo, BA Joana de Gusmão Children’s Hospital
  • Catherine S. Isoppo, BA National School of Public Health, NOVA University Lisbon (ENSP-NOVA) https://orcid.org/0000-0001-7202-3402
  • Louíse V. Hoffmeister, MS National School of Public Health, NOVA University Lisbon (ENSP-NOVA) https://orcid.org/0000-0002-8858-5693

DOI:

https://doi.org/10.33940/culture/2022.6.3

Keywords:

pediatric patient safety, serious adverse event, pediatric medication error, pediatric adverse event, root cause analysis medication, patient safety improvement

Abstract

Visual Abstract

Introduction: Health systems currently present a great degree of complexity, which provides risks to patients related to healthcare, and the possibility of incidents with or without harm. Patient safety culture highlights the need to investigate, analyze, and mitigate incidents to reduce risks to the patient. Medication errors have a high potential to do harm in pediatric hospital routines and most of them are preventable. The objective of this study was to describe a severe drug-related adverse event and present the root cause analysis and implemented improvements.

Methods: A 3-month-old patient undergoing therapeutic cardiac catheterization at another hospital presented with cardiorespiratory arrest in post-procedure progression after returning to the hospital of origin; this was a case of adverse events with medication use in pediatrics. Root cause analysis was performed using the London Protocol. Brainstorming was conducted to study the main improvements to be proposed to the institution.

Results: Improvements were identified and implemented in various processes, such as patient transport, drug dispensing, and administration. Root cause analysis made it possible to select the processes and departments involved and detect possible factors related to the adverse event. These changes were monitored, and after five years the indicators show that they have become consolidated.

Conclusions: The explanation of this event shows how a hospital service can review workflows and processes and implement improvements to reduce risks and prevent further damage through the analysis of an adverse event.

Author Biographies

Cecilia T. Bigio, MD, Joana de Gusmão Children’s Hospital

Cecilia T. Bigio (cecbigio@gmail.com) has been a pediatrician at the Joana de Gusmão Children’s Hospital in Florianópolis, Santa Catarina, in Brazil since 2010. In addition to working in the hospital’s pediatric intensive care unit, the chronic patients unit, and emergency medical service, she is a member of the bioethics committee and the electronic medical record committee. Currently on leave from activities in Brazil, she is working in Portugal in the pediatric emergency department at Hospital Santa Maria Maior – Barcelos and Hospital Senhora da Oliveira – Guimarães.

Marcia R. Rodrigues, Joana de Gusmão Children’s Hospital

Marcia R. Rodrigues is a nursing technician in an urgent and emergency unit at Joana de Gusmão Children’s Hospital (HIJG) in Florianópolis, Santa Catarina, in Brazil, with extensive experience in the areas of adult emergency, pediatrics, and neonatology, as well as hospital management. Rodrigues has served on the Safety and Patient Council of the State of Santa Catarina, the Institutional Development Support Program of the Unified Health System (PROADI-SUS) Collaborative Project, and the Patient Safety Center and Quality Office at HIJG.

Carolina de Melo, BA, Joana de Gusmão Children’s Hospital

Carolina de Melo is a nurse in the pediatric oncology service at the Joana de Gusmão Children’s Hospital (HIJG) in Florianópolis, Santa Catarina, in Brazil. Previously she worked at the Oncological Research Center (CEPON) in Santa Catarina in palliative care, and in various roles at HIJG, including in the oncohematology unit, in patient safety, and on the Permanent Commission for Technical Opinion.

Catherine S. Isoppo, BA, National School of Public Health, NOVA University Lisbon (ENSP-NOVA)

Catherine S. Isoppo is a guest researcher and tutor of the International Course in Quality in Health and Patient Safety at the National School of Public Health, NOVA University Lisbon (ENSP-NOVA) and head of operations at NoHarm.ai in Portugal. Recently, she was a researcher and technical consultant at the Safe Patient Project of the Institutional Development Support Program of the Unified Health System (PROADI-SUS) – Hospital Moinhos de Vento with participation in the PROADI-SUS Collaborative Project. She also has experience in infection control and hospital pharmacy, with an emphasis on pharmacovigilance and clinical pharmacy.

Louíse V. Hoffmeister, MS, National School of Public Health, NOVA University Lisbon (ENSP-NOVA)

Louíse V. Hoffmeister is affiliated with the Public Health Research Center at the National School of Public Health, NOVA University Lisbon (ENSP-NOVA); the Comprehensive Health Research Center; and the Nursing Research, Innovation and Development Centre of Lisbon, Nursing School of Lisbon, in Portugal. A doctoral candidate in public health at ENSP-NOVA with a master’s degree in nursing from the University of Minho, she is involved with improvement projects in public hospitals and research projects on patient safety, health management, and care integration.

References

Reason JT. Human Error. Cambridge, UK: Cambridge University Press; 1990.

Vincent CA. Understanding and Responding to Adverse Events, N Engl J Med. 2003;348:1051-1056.

Goedecke T, Ord K, Newbould V, Brosch S, Arlett P. Medication Errors: New EU Good Practice Guide on Risk Minimisation and Error Prevention. Drug Saf. 2016; 39:491-500.

Mueller BU, Neuspiel, DR, Fisher ERS. Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics. 2019;143,2:1-14. https://pediatrics.aappublications.org/content/143/2/e20183649.long

Taylor-Adams S, Vincent C. Systems Analysis of Clinical Incidents: The London Protocol. Clin Risk. 2004 1;10(6):211-20.

Proqualis. Proqualis website. https://proqualis.net. Accessed April 20, 2022.

Agência Nacional de Vigilância Sanitária – Brazilian Health Regulatory Agency. Investigation of Adverse Events in Health Services. ANVISA website. https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/investigacao-de-eventos-adversos-em-servicos-de-saude/. Published 2016. Accessed April 20, 2022.

Institute for Healthcare Improvement. IHI website. http://www.ihi.org/. Accessed April 20, 2022.

article title and abstract on blue abstract background.

Published

2022-06-17

How to Cite

Bigio, C. T., Rodrigues, M. R., de Melo, C., Isoppo, C. S., & Hoffmeister, L. V. (2022). Implementation of Improvements Based on the Analysis of Severe Adverse Events in Pediatric Patients. Patient Safety, 4(2), 34–42. https://doi.org/10.33940/culture/2022.6.3

Issue

Section

Original Research and Articles
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