Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children.
BACKGROUND
Errors in are estimated to occur with an incidence of 3.7-16.6% in hospitalized patients. The application of systems for detection of adverse events is becoming a widespread reality in healthcare. Incident reporting (IR) and failure mode and effective analysis (FMEA) are strategies widely used to detect errors, but no studies have combined them in the setting of a pediatric intensive care unit (PICU).


AIM
The aim of our study was to describe the trend of IR in a PICU and evaluate the effect of FMEA application on the number and severity of the errors detected.


METHODS
With this prospective observational study, we evaluated the frequency IR documented in standard IR forms completed from January 2009 to December 2012 in the PICU of Woman's and Child's Health Department of Padova. On the basis of their severity, errors were classified as: without outcome (55%), with minor outcome (16%), with moderate outcome (10%), and with major outcome (3%); 16% of reported incidents were 'near misses'. We compared the data before and after the introduction of FMEA.


RESULTS
Sixty-nine errors were registered, 59 (86%) concerning drug therapy (83% during prescription). Compared to 2009-2010, in 2011-2012, we noted an increase of reported errors (43 vs 26) with a reduction of their severity (21% vs 8% 'near misses' and 65% vs 38% errors with no outcome).


CONCLUSION
With the introduction of FMEA, we obtained an increased awareness in error reporting. Application of these systems will improve the quality of healthcare services.
['Daverio|Marco|M|', 'Fino|Giuliana|G|', 'Luca|Brugnaro|B|', 'Zaggia|Cristina|C|', 'Pettenazzo|Andrea|A|', 'Parpaiola|Antonella|A|', 'Lago|Paola|P|', 'Amigoni|Angela|A|']
D000293:Adolescent D002648:Child D002675:Child, Preschool D003422:Critical Care D016638:Critical Illness D004282:Documentation D004358:Drug Therapy D005568:Forms and Records Control D006801:Humans D007223:Infant D007231:Infant, Newborn D015278:Intensive Care Units, Pediatric D019300:Medical Errors D011446:Prospective Studies D058996:Quality Improvement D012308:Risk Management D013647:Task Performance and Analysis D017211:Treatment Failure D016896:Treatment Outcome
medical errors incident reporting pediatric intensive care unit critical care healthcare quality