메뉴 건너뛰기




Volumn 41, Issue 12, 2015, Pages 550-560

The well-defined pediatric ICU: Active surveillance using nonmedical personnel to capture less serious safety events

Author keywords

[No Author keywords available]

Indexed keywords

CHILD; COLLEGE; CONTROLLED STUDY; DATABASE MANAGEMENT SYSTEM; DOCTOR PATIENT RELATION; HOSPITAL MANAGEMENT; HUMAN; INTENSIVE CARE UNIT; LEADERSHIP; MAJOR CLINICAL STUDY; MINNESOTA; QUANTITATIVE STUDY; SAFETY; TABLET; DOCUMENTATION; HEALTH CARE QUALITY; HOSPITAL PERSONNEL; OBSERVER VARIATION; ORGANIZATION AND MANAGEMENT; PATIENT SAFETY; PROCEDURES; PROSPECTIVE STUDY;

EID: 84956576271     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/s1553-7250(15)41072-4     Document Type: Article
Times cited : (4)

References (59)
  • 1
    • 84868128317 scopus 로고    scopus 로고
    • Reducing mortality related to adverse events in children
    • Shin AY, Longhurst C, Sharek PJ. Reducing mortality related to adverse events in children. Pediatr Clin North Am. 2012;59(6):1293-1306.
    • (2012) Pediatr Clin North Am , vol.59 , Issue.6 , pp. 1293-1306
    • Shin, A.Y.1    Longhurst, C.2    Sharek, P.J.3
  • 2
    • 78951486959 scopus 로고    scopus 로고
    • Critical incidents in paediatric critical care: Who is at risk?
    • Niesse OW, Sennhauser FH, Frey B. Critical incidents in paediatric critical care: Who is at risk? Eur J Pediatr. 2011;170(2):193-198.
    • (2011) Eur J Pediatr , vol.170 , Issue.2 , pp. 193-198
    • Niesse, O.W.1    Sennhauser, F.H.2    Frey, B.3
  • 3
    • 0038315446 scopus 로고    scopus 로고
    • Patient safety events during pediatric hospitalizations
    • Miller MR, Elixhauser A, Zhan C. Patient safety events during pediatric hospitalizations. Pediatrics. 2003;111(6 Pt 1):1358-1366.
    • (2003) Pediatrics , vol.111 , Issue.6 , pp. 1358-1366
    • Miller, M.R.1    Elixhauser, A.2    Zhan, C.3
  • 4
    • 16844373959 scopus 로고    scopus 로고
    • Adverse events and preventable adverse events in children
    • Woods D, et al. Adverse events and preventable adverse events in children. Pediatrics. 2005;115(1):155-160.
    • (2005) Pediatrics , vol.115 , Issue.1 , pp. 155-160
    • Woods, D.1
  • 5
    • 78249240873 scopus 로고    scopus 로고
    • Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis
    • Muething SE, et al. Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis. Qual Saf Health Care. 2010;19(5):435-439.
    • (2010) Qual Saf Health Care , vol.19 , Issue.5 , pp. 435-439
    • Muething, S.E.1
  • 6
    • 0034025720 scopus 로고    scopus 로고
    • Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: Experience with the system approach
    • Jan
    • Frey B, et al. Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: Experience with the system approach. Intensive Care Med. 2000Jan;26(1):69-74.
    • (2000) Intensive Care Med. , vol.26 , Issue.1 , pp. 69-74
    • Frey, B.1
  • 7
    • 0141922804 scopus 로고    scopus 로고
    • Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization
    • Oct 8
    • Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003Oct 8;290(14):1868-1874.
    • (2003) JAMA , vol.290 , Issue.14 , pp. 1868-1874
    • Zhan, C.1    Miller, M.R.2
  • 8
    • 34547611678 scopus 로고    scopus 로고
    • Nov 19, Accessed Oct 31, 2015
    • The Joint Commission. Sentinel Event Policy and Procedures. Nov 19, 2014. Accessed Oct 31, 2015. http://www.jointcommission.org/Sentinel-Event-Policy-and-Procedures/.
    • (2014) Sentinel Event Policy and Procedures
  • 9
    • 48949099379 scopus 로고    scopus 로고
    • Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality indicators: A multicenter study of freestanding children's hospitals
    • Kronman MP, et al. Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality indicators: A multicenter study of freestanding children's hospitals. Pediatrics. 2008;121(6):e1653-1659.
    • (2008) Pediatrics , vol.121 , Issue.6 , pp. e1653-e1659
    • Kronman, M.P.1
  • 10
    • 78049326640 scopus 로고    scopus 로고
    • Hospitals own up to errors
    • Accessed Dec 2013
    • Landro L. Hospitals own up to errors. Wall Street Journal.Accessed Dec 2013. http://on.wsj.com/1zERlmO
    • Wall Street Journal
    • Landro, L.1
  • 12
    • 0034681819 scopus 로고    scopus 로고
    • Human error: Models and management
    • Mar 18
    • Reason J. Human error: Models and management. BMJ. 2000Mar 18;320(7237):768-770.
    • (2000) BMJ , vol.320 , Issue.7237 , pp. 768-770
    • Reason, J.1
  • 14
    • 84864245630 scopus 로고    scopus 로고
    • Patient safety reporting systems: Sustained quality improvement using a multidisciplinary team and "Good Catch" award
    • Herzer KR, et al. Patient safety reporting systems: Sustained quality improvement using a multidisciplinary team and "Good Catch" award. Jt Comm J Qual Patient Saf. 2012;38(8):339-347.
    • (2012) Jt Comm J Qual Patient Saf , vol.38 , Issue.8 , pp. 339-347
    • Herzer, K.R.1
  • 15
    • 84938681103 scopus 로고    scopus 로고
    • Incident learning in pursuit of high reliability: Implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department
    • Gabriel PE, et al. Incident learning in pursuit of high reliability: Implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. Jt Comm J Qual Patient Saf. 2015;41(4):160-168.
    • (2015) Jt Comm J Qual Patient Saf , vol.41 , Issue.4 , pp. 160-168
    • Gabriel, P.E.1
  • 16
    • 79959340273 scopus 로고    scopus 로고
    • A prospective study of paediatric cardiac surgical microsystems: Assessing the relationships between non-routine events, teamwork and patient outcomes
    • Schraagen JM, et al. A prospective study of paediatric cardiac surgical microsystems: Assessing the relationships between non-routine events, teamwork and patient outcomes. BMJ Qual Saf. 2011;20(7):599-603.
    • (2011) BMJ Qual Saf , vol.20 , Issue.7 , pp. 599-603
    • Schraagen, J.M.1
  • 17
    • 77957571620 scopus 로고    scopus 로고
    • Prevalence of adverse events in pediatric intensive care units in the United States
    • Agarwal S, et al. Prevalence of adverse events in pediatric intensive care units in the United States. Pediatr Crit Care Med. 2010;11(5):568-578.
    • (2010) Pediatr Crit Care Med. , vol.11 , Issue.5 , pp. 568-578
    • Agarwal, S.1
  • 18
    • 34147128589 scopus 로고    scopus 로고
    • Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit
    • Buckley MS, et al. Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. Pediatr Crit Care Med. 2007;8(2):145-152.
    • (2007) Pediatr Crit Care Med. , vol.8 , Issue.2 , pp. 145-152
    • Buckley, M.S.1
  • 19
    • 84868629658 scopus 로고    scopus 로고
    • Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool
    • Kirkendall ES, et al. Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. Pediatrics. 2012;130(5):e1206-1214.
    • (2012) Pediatrics , vol.130 , Issue.5 , pp. e1206-e1214
    • Kirkendall, E.S.1
  • 20
    • 67649620074 scopus 로고    scopus 로고
    • Cardiovascular medication errors in children
    • Alexander DC, et al. Cardiovascular medication errors in children. Pediatrics. 2009;124(1):324-332.
    • (2009) Pediatrics , vol.124 , Issue.1 , pp. 324-332
    • Alexander, D.C.1
  • 21
    • 0031023762 scopus 로고    scopus 로고
    • An alternative strategy for studying adverse events in medical care
    • Feb 1
    • Andrews LB, et al. An alternative strategy for studying adverse events in medical care. Lancet. 1997Feb 1;349(9048):309-313.
    • (1997) Lancet , vol.349 , Issue.9048 , pp. 309-313
    • Andrews, L.B.1
  • 22
    • 0037244466 scopus 로고    scopus 로고
    • Measuring errors and adverse events in health care
    • Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med. 2003;18(1):61-67.
    • (2003) J Gen Intern Med. , vol.18 , Issue.1 , pp. 61-67
    • Thomas, E.J.1    Petersen, L.A.2
  • 23
    • 77649096722 scopus 로고    scopus 로고
    • If only . . .: Failed, missed and absent error recovery opportunities in medication errors
    • Habraken MM, van der Schaaf. If only . . .: Failed, missed and absent error recovery opportunities in medication errors. Qual Saf Health Care. 2010;19(1):37-41.
    • (2010) Qual Saf Health Care , vol.19 , Issue.1 , pp. 37-41
    • Habraken, M.M.1    Van Der Schaaf2
  • 25
    • 0034681861 scopus 로고    scopus 로고
    • Reporting and preventing medical mishaps: Lessons from nonmedical near miss reporting systems
    • Mar 18
    • Barach P, Small SD. Reporting and preventing medical mishaps: Lessons from nonmedical near miss reporting systems. BMJ. 2000Mar 18;320(7237):759-763.
    • (2000) BMJ , vol.320 , Issue.7237 , pp. 759-763
    • Barach, P.1    Small, S.D.2
  • 26
    • 0035946697 scopus 로고    scopus 로고
    • Medication errors and adverse drug events in pediatric inpatients
    • Kaushal R, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-2120.
    • (2001) JAMA , vol.285 , Issue.16 , pp. 2114-2120
    • Kaushal, R.1
  • 27
    • 84946913153 scopus 로고    scopus 로고
    • Apr 30, Accessed Oct 31, 2015
    • Pennsylvania Patient Safety Authority. 2014 Annual Report. Apr 30, 2015. Accessed Oct 31, 2015. http://patientsafetyauthority.org/PatientSafetyAuthority/Documents/Annual-Report-2014.pdf.
    • (2015) 2014 Annual Report
  • 28
    • 0141484568 scopus 로고    scopus 로고
    • Detecting adverse events for patient safety research: A review of current methodologies
    • Murff HJ, et al. Detecting adverse events for patient safety research: A review of current methodologies. J Biomed Inform. 2003;36(1-2):131-143.
    • (2003) J Biomed Inform , vol.36 , Issue.1-2 , pp. 131-143
    • Murff, H.J.1
  • 29
    • 33745741780 scopus 로고    scopus 로고
    • Quality and safety in the intensive care unit
    • Stockwell DC, Slonim AD. Quality and safety in the intensive care unit. J Intensive Care Med. 2006;21(4):199-210.
    • (2006) J Intensive Care Med. , vol.21 , Issue.4 , pp. 199-210
    • Stockwell, D.C.1    Slonim, A.D.2
  • 30
    • 78650314282 scopus 로고    scopus 로고
    • Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit
    • Dec; PMID: 20511597
    • Silas R, Tibballs J. Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit. Qual Saf Health Care. 2010Dec;19(6):568-571. PMID: 20511597
    • (2010) Qual Saf Health Care , vol.19 , Issue.6 , pp. 568-571
    • Silas, R.1    Tibballs, J.2
  • 31
    • 84858753273 scopus 로고    scopus 로고
    • Learning from near misses: From quick fixes to closing off the Swiss-cheese holes
    • Jeffs L, et al. Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. BMJ Qual Say. 2012;21(4):287-294.
    • (2012) BMJ Qual Say , vol.21 , Issue.4 , pp. 287-294
    • Jeffs, L.1
  • 32
    • 79955618085 scopus 로고    scopus 로고
    • 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured
    • Classen DC, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581-589.
    • (2011) Health Aff (Millwood) , vol.30 , Issue.4 , pp. 581-589
    • Classen, D.C.1
  • 33
    • 84880531898 scopus 로고    scopus 로고
    • Erratum: 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured
    • Classen DC, et al. Erratum: 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwod). 2011;30(6):1217.
    • (2011) Health Aff (Millwod) , vol.30 , Issue.6 , pp. 1217
    • Classen, D.C.1
  • 34
    • 78649645940 scopus 로고    scopus 로고
    • Critical incident monitoring in paediatric and adult critical care: From reporting to improved patient outcomes?
    • Frey B, Schwappach D. Critical incident monitoring in paediatric and adult critical care: From reporting to improved patient outcomes? Curr Opin Crit Care. 2010;16(6):649-653.
    • (2010) Curr Opin Crit Care , vol.16 , Issue.6 , pp. 649-653
    • Frey, B.1    Schwappach, D.2
  • 35
    • 79952200427 scopus 로고    scopus 로고
    • Building safer systems through critical occurrence reviews: Nine years of learning
    • Stevens P, et al. Building safer systems through critical occurrence reviews: Nine years of learning. Healthc Q. 2010;13 Spec No:74-80.
    • (2010) Healthc Q , vol.13
    • Stevens, P.1
  • 36
    • 23644453746 scopus 로고    scopus 로고
    • Real time patient safety audits: Improving safety every day
    • Ursprung R, et al. Real time patient safety audits: Improving safety every day. Qual Saf Health Care. 2005;14(4):284-289.
    • (2005) Qual Saf Health Care , vol.14 , Issue.4 , pp. 284-289
    • Ursprung, R.1
  • 37
    • 77956924128 scopus 로고    scopus 로고
    • Responding to patient safety incidents: The "seven pillars"
    • McDonald TB, et al. Responding to patient safety incidents: The "seven pillars." Qual Saf Health Care. 2010;19(6):e11.
    • (2010) Qual Saf Health Care , vol.19 , Issue.6 , pp. e11
    • McDonald, T.B.1
  • 38
    • 80052104403 scopus 로고    scopus 로고
    • Using prospective clinical surveillance to identify adverse events in hospital
    • Forster AJ, et al. Using prospective clinical surveillance to identify adverse events in hospital. BMJ Qual Saf. 2011;20(9):756-63.
    • (2011) BMJ Qual Saf , vol.20 , Issue.9 , pp. 756-763
    • Forster, A.J.1
  • 39
    • 84924935961 scopus 로고    scopus 로고
    • Application of a trigger tool in near real time to inform quality improvement activities: A prospective study in a general medicine ward
    • Wong BM, et al. Application of a trigger tool in near real time to inform quality improvement activities: A prospective study in a general medicine ward. BMJ Qual Saf. 2015;24(4):272-281.
    • (2015) BMJ Qual Saf , vol.24 , Issue.4 , pp. 272-281
    • Wong, B.M.1
  • 40
    • 0037302945 scopus 로고    scopus 로고
    • PIM 2: A revised version of the Paediatric Index of Mortality
    • Slater A, Shann F, Pearson G; Paediatric Index of Mortality (PIM) Study Group. PIM 2: A revised version of the Paediatric Index of Mortality. Intensive Care Med. 2003;29(2):278-285.
    • (2003) Intensive Care Med. , vol.29 , Issue.2 , pp. 278-285
    • Slater, A.1    Shann, F.2    Pearson, G.3
  • 41
    • 76049094205 scopus 로고    scopus 로고
    • Decreasing PICU catheter-associated bloodstream infections: NACHRI's quality transformation efforts
    • Miller MR, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI's quality transformation efforts. Pediatrics. 2010;125(2):206-213.
    • (2010) Pediatrics , vol.125 , Issue.2 , pp. 206-213
    • Miller, M.R.1
  • 42
    • 0035069589 scopus 로고    scopus 로고
    • Institutional resilience in healthcare systems
    • Carthey J, de Leval MR. Reason JT. Institutional resilience in healthcare systems. Qual Health Care. 2001;10(1):29-32.
    • (2001) Qual Health Care , vol.10 , Issue.1 , pp. 29-32
    • Carthey, J.1    De Leval, M.R.2    Reason, J.T.3
  • 43
    • 84973587732 scopus 로고
    • A coefficient of agreement for nominal scales
    • Cohen J. A coefficient of agreement for nominal scales. Educational and Psychological Measurement. 1960;20(1):37-46.
    • (1960) Educational and Psychological Measurement , vol.20 , Issue.1 , pp. 37-46
    • Cohen, J.1
  • 45
    • 84887045756 scopus 로고    scopus 로고
    • Developing a new, national approach to surveillance for ventilator-associated events
    • Magill SS, et al. Developing a new, national approach to surveillance for ventilator-associated events. Crit Care Med. 2013;41(11):2467-2475.
    • (2013) Crit Care Med. , vol.41 , Issue.11 , pp. 2467-2475
    • Magill, S.S.1
  • 46
  • 48
    • 34447317568 scopus 로고    scopus 로고
    • Preventable harm occurring to critically ill children
    • Larsen GY, et al. Preventable harm occurring to critically ill children. Pediatr Crit Care Med. 2007;8(4):331-336.
    • (2007) Pediatr Crit Care Med. , vol.8 , Issue.4 , pp. 331-336
    • Larsen, G.Y.1
  • 49
    • 84930585667 scopus 로고    scopus 로고
    • A trigger tool to detect harm in pediatric inpatient settings
    • Stockwell DC, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036-1042.
    • (2015) Pediatrics , vol.135 , Issue.6 , pp. 1036-1042
    • Stockwell, D.C.1
  • 50
    • 77953816069 scopus 로고    scopus 로고
    • Critical incident reporting and learning
    • Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010;105(1):69-75.
    • (2010) Br J Anaesth. , vol.105 , Issue.1 , pp. 69-75
    • Mahajan, R.P.1
  • 51
    • 0028097184 scopus 로고
    • Error in medicine
    • Dec 21
    • Leape LL. Error in medicine. JAMA. 1994Dec 21;272(23):1851-1857.
    • (1994) JAMA , vol.272 , Issue.23 , pp. 1851-1857
    • Leape, L.L.1
  • 52
    • 84974853091 scopus 로고    scopus 로고
    • Sorra J, et al. Mar Publication No. 14-0019-EF. Accessed Oct 31, 2015
    • Agency for Healthcare Research and Quality (AHRQ). Hospital Survey on Patient Safety Culture: 2014 User Comparative Database Report. Sorra J, et al. Mar 2014. Publication No. 14-0019-EF. Accessed Oct 31, 2015. http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/2014/hsops14pt1.pdf.
    • (2014) Hospital Survey on Patient Safety Culture: 2014 User Comparative Database Report
  • 53
    • 0345471068 scopus 로고    scopus 로고
    • Evaluation of two methods for quality improvement in intensive care: Facilitated incident monitoring and retrospective medical chart review
    • Beckmann U, et al. Evaluation of two methods for quality improvement in intensive care: Facilitated incident monitoring and retrospective medical chart review. Crit Care Med. 2003;31(4):1006-1011.
    • (2003) Crit Care Med. , vol.31 , Issue.4 , pp. 1006-1011
    • Beckmann, U.1
  • 54
    • 33244493122 scopus 로고    scopus 로고
    • Attitudes and barriers to incident reporting: A collaborative hospital study
    • Evans SM, et al. Attitudes and barriers to incident reporting: A collaborative hospital study. Qual Saf Health Care. 2006;15(1):39-43.
    • (2006) Qual Saf Health Care , vol.15 , Issue.1 , pp. 39-43
    • Evans, S.M.1
  • 55
    • 84929308509 scopus 로고    scopus 로고
    • Junior doctors' views on reporting concerns about patient safety: A qualitative study
    • Hooper P, et al. Junior doctors' views on reporting concerns about patient safety: A qualitative study. Postgrad Med J. 2015;91(1075):251-256.
    • (2015) Postgrad Med J , vol.91 , Issue.1075 , pp. 251-256
    • Hooper, P.1
  • 56
    • 3242778734 scopus 로고    scopus 로고
    • Attitudes of doctors and nurses towards incident reporting: A qualitative analysis
    • Jul 5
    • Kingston MJ, et al. Attitudes of doctors and nurses towards incident reporting: A qualitative analysis. Med J Aust. 2004Jul 5;181(1):36-39.
    • (2004) Med J Aust , vol.181 , Issue.1 , pp. 36-39
    • Kingston, M.J.1
  • 57
    • 84874937900 scopus 로고    scopus 로고
    • Alteplase use for malfunctioning central venous catheters correlates with catheter-associated bloodstream infections
    • Rowan C, et al. Alteplase use for malfunctioning central venous catheters correlates with catheter-associated bloodstream infections. Pediatr Crit Care Med. 2013;14(3):306-309.
    • (2013) Pediatr Crit Care Med. , vol.14 , Issue.3 , pp. 306-309
    • Rowan, C.1
  • 58
    • 38649113873 scopus 로고    scopus 로고
    • Patients' safety: Think and act locally
    • Feb 2
    • Larsen G, Parker H. Patients' safety: Think and act locally. Lancet. 2008Feb 2;371(9610):364-365.
    • (2008) Lancet , vol.371 , Issue.9610 , pp. 364-365
    • Larsen, G.1    Parker, H.2
  • 59
    • 84943350050 scopus 로고    scopus 로고
    • Using a quantitative risk register to promote learning from a patient safety reporting system
    • Mansfield JG, et al. Using a quantitative risk register to promote learning from a patient safety reporting system. Jt Comm J Qual Patient Saf. 2015;41(2):76-86.
    • (2015) Jt Comm J Qual Patient Saf , vol.41 , Issue.2 , pp. 76-86
    • Mansfield, J.G.1


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.