ABSTRACT 895

Abstract

Background and aims: Traditional safety measurement involves retrospective patient harm analysis. This offers useful learning but does not evaluate current safety and is reactive not proactive. Pre-emptive safety reviews may be valuable but there is limited paediatric critical care work. Aims: This is a pilot study in a known high risk patient group aiming to identify and classify hazard categories, allowing introduction of targeted risk reduction measures and developing frameworks for future proactive safety evaluations. Methods: Children undergoing moderate risk cardiac surgery were followed from hospital admission to discharge. Data was gathered through observation, contextual inquiry, staff and parent interviews, and photography. The Systems Engineering Initiative for Patient Safety (SEIPS) framework was used for analysis. Reported hazards were validated by clinicians. Institutional consent requirement was waivered. Results: 6 children were observed over 75 hours, with 194 primary hazard categories identified. Only 16% were encountered on PICU. The major SEIPS hazard categories related to “Person” and “Organisation”: teamwork, interruptions, planning and capacity. There was commonality among all care areas in identified themes. To fully reflect these, the SEIPS framework was modified including multidisciplinary communication, patient experience and staff / bed capacity.FigureConclusions: The modified SEIPS framework is a useful categorization facilitating identification of multiple potential hazards common across care areas and enabling safer pathway design.