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

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.