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 risk...
Adverse Events In Pediatric Patients Events In Pediatric Patients Root Cause London Protocol Adverse Event Drug Dispensing Severe Adverse Event Medication Errors Hospital Service Adverse Events In Patients
AI-powered Research feed
Introducing Weekly Round-ups!Beta
Round-ups are the summaries of handpicked papers around trending topics published every week. These would enable you to scan through a collection of papers and decide if the paper is relevant to you before actually investing time into reading it.
Climate change Research Articles published between Nov 21, 2022 to Nov 27, 2022
Nov 28, 2022
Articles Included: 2
No potential conflict of interest was reported by the authors. The conception and design of the study, acquisition of data, analysis and interpretatio...Read More
Disclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on “as is” basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The Copyright Law.