566

• DOI: 10.1097/01.ccm.0000439807.75341.c3
• Publication Date: 2013-11-26T19:18:01Z
• Authors: Christina Cifra; Kareen Jones; Judith Ascenzi; Utpal Bhalala; Melania Bembea; James Fackler; Marlene Miller
• Keywords: 03 medical and health sciences; 0302 clinical medicine; 3. Good health

Introduction: In addition to traditional incident reporting, the MMC can augment ability surface AEs. Our objective is determine types, severity and preventability of AEs uncovered among patients discussed in a tertiary hospital PICU over specific time period compare these with reported for same cohort through reporting system, Patient Safety Network (PSN). Methods: Two independent reviewers conducted systematic retrospective record review 8 months (Nov2011-June2012). were identified categorized as type, preventability. Discrepancies resolved by 2nd-tier attending nurse. Comparison via PSN was performed. Descriptive statistical analysis done, calculating proportions categorical variables. Results: 48 cases reviewed 212 total from either or (4.4 AEs/patient, 29 AEs/100 patient-days). 169/212(79.7%) MMC, which 85/169(40.1%) specified agenda, while 84/169(49.7%) chart review. 52/212(24.5%) PSN. Only 9/212(4.2%) both The most common types similar each group - medication errors (MMC 31.9%, 51.9%), device-related events 16.0%, 17.3%), communication issues 14.2%, 26.9%). more severe 60.6% requiring prolonged hospitalization/life-sustaining therapy contributing permanent harm/death. less 61.5% causing no harm 28.9% only temporary harm. ranged preventability, 30% certainly preventable 36.3% likely not preventable. 98.1% non-preventable reported. Conclusions: targeted useful adjunct AE surveillance reporting. Overlap between two minimal, providing data on unique, severe, yet still Combining systems results accurate surveillance.