Lessons Learned: Use of Event Reporting by Nurses to Improve Patient Safety and Quality

Journal of Pediatric Nursing

Volumn 26, Issue 2, 2011, Pages 149-155

  Hession Laband, Eileen ^a   Mantell, Patricia ^a  

^a BOSTON CHILDREN S HOSPITAL   (United States)

Author keywords

Event reporting; Medical errors; Medication error; Patient safety; Underreporting

Indexed keywords

ARTICLE; EDUCATION; HOSPITAL; HOSPITAL INFORMATION SYSTEM; HUMAN; MEDICAL ERROR; NURSING STAFF; ORGANIZATION; PEDIATRIC NURSING; PERSONNEL MANAGEMENT; RISK MANAGEMENT; TOTAL QUALITY MANAGEMENT; UNITED STATES;

BOSTON; HOSPITAL INFORMATION SYSTEMS; HOSPITALS, PEDIATRIC; HUMANS; MEDICAL ERRORS; NURSING STAFF, HOSPITAL; ORGANIZATIONAL CULTURE; PEDIATRIC NURSING; QUALITY IMPROVEMENT; RISK MANAGEMENT; STAFF DEVELOPMENT;

EID: 79952668916     PISSN: 08825963     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.pedn.2010.12.005     Document Type: Article

References (21)

1. Agency for Healthcare Research and Quality. Patient Safety Network: A National Patient Safety Resource. 2006 website. http://psnet.ahrq.gov/glossary.
2. Avery J., Beyea S.C., Campion P. Active error management: Use of Web-based reporting system to support patient safety initiatives. Journal of Nursing Administration 2005, 35:81-85.
3. Ferranti J., Horvath M.M., Kozart H., Whitehurst J., Eckstrand J. Reevaluating the safety profile of pediatrics: A comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment. Pediatrics 2008, 121:e1201-e1207.
4. Holdsworth M.T., Fichtl R.E., Behta M., Raisch D.W., Mendez-Rico E., Adams A., et al. Incidence and impact of adverse drug events in pediatric inpatients. Archives of Pediatrics and Adolescent Medicine 2003, 157:60-65.
5. Kaplan H.S., Fastman B.R. Organization of event reporting data for sense making and system improvement. Quality and Safety in Healthcare 2003, 12:68-72.
6. Kaushal R., Bates D.W., Landrigan C., McKenna K.J., Clapp M.D., Federico F., et al. Medication errors and adverse drug events in pediatric inpatients. Journal of the American Medical Association 2001, 285:2114-2120.
7. Kohn L.T., Corrigan J.M., Donaldson M.S. To err is human: Building a safer health system 2000, National Academy Press, Washington, DC.
8. Kolovos N.S., Bratton S.L., Levy F.H. A novel error-reporting tool in pediatric intensive care. Journal of Healthcare Quality 2008, 30:43-50.
9. Koppel R., Wetterneck T., Telles J.L., Karsh B-T. Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association 2008, 15:408-423.
10. Langley G.L., Nolan K.M., Nolan T.W., Norman C.L., Provost L.P. The improvement guide: A practical approach to enhancing organizational performance 2009, Jossey-Bass, SanFrancisco, CA. 2nd ed.
11. Lannon C.M., Coven B.J., Lane France F., Hickson G.B., Miles P.V., Swanson J.T., et al. Principles of patient safety in pediatrics. Pediatrics 2001, 107:1473-1475.
12. Lehman D.F., Page N., Kirschman K., Sedore A., Guharoy R., Medicis J., et al. Every error a treasure: Improving medication use with a nonpunitive reporting system. The Joint Commission Journal on Quality and Patient Safety 2007, 33:401-407.
13. Miller M.R., Zhan C. Pediatric patient safety in hospitals: A national picture in 2000. Pediatrics 2004, 113:1741-1746.
14. Proctor M.L., Pastore J., Gerstle J.T., Langer J.C. Incidence of medical error and adverse outcomes on a pediatric general surgery service. Journal of Pediatric Surgery 2003, 38:1361-1365.
15. Pronovost P.J., Holzmueller C.G., Young J., Whitney P., Wu A.W., Thompson D.A., et al. Using incident reporting to improve patient safety: A conceptual model. Journal of Patient Safety 2007, 3:27-33.
16. Richardson W. Innovations in patient safety management: Bedside nurses' assessment of near misses. Topics in Emergency Medicine 2006, 28:154-160.
17. Stratton K., Blegen M.A., Pepper G., Vaughn T. Reporting of medication errors by pediatric nurses. Journal of Pediatric Nursing 2004, 19:385-392.
18. Suresh G., Horbar J.D., Plesk P., Gray J., Edwards W.H., Shiono P.H., et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 2004, 113:1609-1618.
19. Taylor J.A., Brownstein D., Christakis D.A., Blackburn S., Strandjord T.P., Klein E., et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics 2004, 114:729-735.
20. Woods D., Thomas E., Holl J., Altman S., Brennan T. Adverse events and preventable adverse events in children. Pediatrics 2005, 115:155-160.
21. Zhan C., Smith S.R., Keyes M.A., Hicks R.W., Cousins D.D., Clancy C.M. How useful are voluntary medication reports? The case of Warfarin-related medication errors. The Joint Commission Journal on Quality and Patient Safety 2008, 34:37-45.