Anatomy of a patient safety event: a pediatric patient safety taxonomy

Abstract

Background: Idiosyncratic terminology and frameworks in the study of patient safety have been tolerated but are increasingly problematic. Agreement on standard language and frameworks is needed for optimal improvement and dissemination of knowledge about patient safety. Methods: Patient safety events were assessed using critical incident analysis, a method used to classify risks that has been more recently applied to medicine. Clinician interviews and clinician reports to a web based reporting system were used for analysis of hospital based and ambulatory care events, respectively. Events were classified independently by three investigators. Results: A pediatric patient safety taxonomy, relevant to both hospital based and ambulatory pediatric care, was developed from the analysis of 122 hospital based and 144 ambulatory care events. It is composed of four main categories: (1) problem type; (2) domain of medicine; (3) contributing factors in the patient (child-specific), environment (latent conditions) and care providers (human factors); and (4) outcome or result of the event and level of harm. A classification of preventive mechanisms was also developed. Inter-rater reliability of classifications ranged from 72% to 86% for sub-categories of the taxonomy.Conclusions: This patient safety taxonomy reflects the nature of events that occur in both pediatric hospital based and ambulatory care settings. It is flexible in its construction, permits analysis to begin at any point, and depicts the relationships and interactions of elements of an event.

Patient Error: A Preliminary Taxonomy

“…Complementing classifi cations of medical error 22,28,31 in nursing 32 and family practice, 4-10 we wanted to construct a taxonomy of patient error that could organize patient and professional perspectives on how patients can err and when. We wanted to elicit these perspectives in structured group activities involving patients in a community setting and primary care professionals.…”

“…14(p33) With some exceptions, [15][16][17][18][19] however, patients' contribution to their own suboptimal health 20,21 has not usually been conceptualized as error. Almost all the taxonomies of medical error, [4][5][6]8,9,22 do not discuss patients' contribution to error, or they acknowledge this contribution peripherally, 23 perhaps because patient error is a sensitive issue. It is easy to confuse human error with blame and to view patients, in particular, as incapable of error because they can be sick and tend to have reduced power in their interactions with clinicians and the health system.…”

Patient safety problems in adolescent medical care

“…Through a text-based constant comparative analysis of the transcribed interview data, a classification system was inductively developed for the types of problems that occur in pediatric patient safety problems and potential preventive mechanisms for these problems [15]. Factors related to theoretical vulnerabilities to the occurrence of errors and adverse events, in medical care, in children of all ages, were identified through review of the literature [16].…”

A Morbidity and Mortality Conference-Based Classification System for Adverse Events: Surgical Outcome Analysis: Part I

“…These include the Applied Strategies for Improving Patient Safety (APIS) [13], the Australian Incident Monitoring Study (AIMS) [14], the Medical Error Reporting SystemTransfusion Medicine (MERS-TM) [15,16], the Joint Commission for Accreditation for Healthcare Organization Patient Safety Event Taxonomy (JCAHO-PSET) [17], The Linnaeus Primary Care Collaborative [18], and the Cognitive Taxonomy [19]. Each system classifies and collects events for inpatient and/or outpatient care settings with varying degrees of validation, and using idiosyncratic terminology or complex classification frameworks [20]. Data sources vary from retrospective malpractice closed claims [14,21] to specific error types or sentinel events (retained foreign bodies, wrong sided surgery [22], unplanned returns [23], anesthetic events [24], respiratory events [25], and to types and locations of clinical care: ambulatory care [18], recovery room [26], or catheterization lab [27].…”