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G325(P) To err is human: thematic characterisation of paediatric clinical incidents within a large district general hospital
  1. S Li,
  2. H Sadreddini,
  3. J Surridge
  1. Derby Children’s Hospital, Royal Derby Hospital, Derby, UK


Aims Our children’s hospital encompasses several acute clinical areas. These include paediatric medical and surgical inpatient wards (including the children’s high dependency ward), the children’s emergency department and the neonatal intensive care unit. Collectively these are busy and challenging environments where the provision of care is increasingly complex. These provide opportunities for errors to occur making unintended consequences to harm more likely. The Francis report published in February 2013 highlighted the need for openness and transparency in regards to patient safety. We reviewed clinical incidents reported within all acute clinical paediatric areas in order to characterise commonly recurring themes.

Method Clinical incident forms from all acute paediatric clinical areas from 1 September 2012 until 31 August 2014 were retrospectively reviewed. Incidents were assessed for the degree of actual harm caused to patients. They were subsequently categorised according to the National Reporting and Learning System incident types for each clinical area. Medications incidents were further sub-classified by type.

Results 872 incident forms involving all acute paediatric clinical areas were submitted over a 24 month period. 67% of all clinical incidents were reported as having insignificant harm to patients and only 2% as catastrophic. The types of incidents reported are shown in Figure 1. Medication errors accounted for a significant percentage of reported incidents within each clinical area (19% children’s emergency department; 30% children’s wards; 26% neonatal intensive care unit). Other commonly reported incidents were infrastructure problems and patient accidents. The types of medication incidents reported are shown in Figure 2. The most commonly reported medication incidents within each clinical area were wrong dose of medicine (26% children’s emergency department), omitted medicines (23% children’s wards) and wrong method of preparation (20% neonatal intensive care unit).

Abstract G325(P) Figure 1

Percentage of reported incident types

Abstract G325(P) Figure 2

Percentage of medication incidents by specified types

Conclusion Incident forms submitted within a children’s hospital should be reviewed so that commonly recurring themes can be identified. Within our hospital medication errors accounted for the majority of reported incidents. Characterisation of these themes have implications for the training of staff which can be tailored to individual paediatric clinical areas.

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