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

¹ Institute for Healthcare Studies, Feinberg School of MedicineNorthwestern University, Chicago, IL, USA
² Department of Medicine, University of ChicagoChicago, IL, USA
³ Institute for Healthcare Studies and Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Children’s Memorial HospitalChicago, IL, USA
⁴ Feinberg School of MedicineNorthwestern University, Chicago, IL, USA
⁵ Department of Medicine, University of Texas Medicial SchoolHonston, TX, USA
⁶ Children’s Memorial HospitalChicago, IL, USA
⁷ Center for Children’s Healthcare Improvement, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel HillChapel Hill, NC, USA

Correspondence to:
Dr D M Woods
Northwestern University, Weibildt Hall, Chicago, IL 60611, USA; woods{at}northwestern.edu 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.

Keywords: ambulatory care; medical errors; paediatrics; classification; critical incident analysis