Pediatric Informatics: Computer Applications in Child Health (Health ...

30 Error Reporting Systems 387
30.3 Medical Error Classification Systems
A number of classification schemes have been proposed to more fully describe
medical errors, which occur when care becomes unsafe. The IOM used a system
that classified medical errors as diagnostic errors, treatment errors, preventative
errors and “others error.” (1) A recent review of the topic added procedural errors
and nosocomial infections. 10 Table 30.1 provides examples of these medical error
categories in pediatrics.
30.4 Existing Error Identification and Detection Methods
Medical error identification is an (under-appreciated) opportunity for improving
care. To take advantage of these opportunities, institutional leadership should
promote practices and attitudes that encourage error identification and reporting
(Table 30.2).
After errors (such as sentinel events) are detected, investigation and system/
process redesign can help to prevent their recurrence. Currently no ideal infrastructure
for error identification exists, and traditional data collection on medical errors
within institutions consists of:
Table 30.1 A classification schema for medical errors in pediatrics 10
Category Examples
Diagnostic Errors Tachypnea attributed to upper respiratory infection when pneumonia
exists
Failure to recognize meningitis as a cause of headache
Failure to identify cyanosis in a child with congenital heart disease
Gastroenteritis diagnosed when appendicitis is the etiology of
abdominal pain
Treatment Errors Any violation of “Five Rights” of medication administration:
Right Patient, Right Drug, Right Route, Right Dose, Right Time
Incorrect patient given abdominal CT
Administering enteral feeds into a central venous line
Nosocomial Infections Hospital acquired RSV infection
Catheter related blood stream infection
Infection related to placement of external ventricular drain
Procedural Errors Inappropriate interpretation of chest X-Rray leading to incorrect
placement of thoracostomy tube
Hemothorax following central line insertion
Placement of tympanostomy tube in opposite ear
Prophylactic Errors Failure to treat ongoing hyperglycemia
Failure to provide preoperative antibiotics in child with structural
heart disease
Failure to provide adequate antibiotic prophylaxis for Pneumocystis
jiroveci in immune suppressed patients