Patient safety in South Africa: PICU adverse event registration

OBJECTIVE:: Adverse event registration is a means to improve patient safety in a PICU. So far it has been used in European and North American countries mainly. We studied adverse events in a South African setting with the aims to 1) assess rates and types of adverse events with two different registration methods and 2) describe characteristics of patients experiencing adverse events. DESIGN:: This study consisted of 1) a retrospective audit of randomly selected patient records and 2) a prospective observational study of real-time registration of AEs during ward rounds. Adverse events were identified using the Child Health Corporation of America - Pediatric Pharmacy Advocacy Group PICU trigger tool. SETTING:: A multidisciplinary 20 bed PICU at the Red Cross War Memorial Children's Hospital in Cape Town. PATIENTS:: The retrospective section of the study involved 80 randomly selected patients who had been discharged from the PICU, and the prospective study involved patients who were present in the PICU between March and June 2012. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: The retrospective audit identified 260 adverse events in 61 patients (50.8 per 100 patient days). Nineteen patients (24%) did not have any adverse events. Catheter complications, hypoglycemia, and endotracheal tube malpositioning requiring repositioning were most frequent. Prospective registration during 58 ward rounds revealed 272 adverse events in 236 patients (27.2 per 100 patient days), particularly catheter complications, nosocomial infection, and surgical complications. Hundred thirty-two patients of the total 236 patients (56%) did not experience an adverse event. Patients experiencing adverse events underwent mechanical ventilation significantly more frequently. Length of stay was significantly associated with number of adverse events. CONCLUSIONS:: The trigger tool method identifies a higher adverse event rate compared with real-time registration. Each method has a unique contribution to yield types of adverse events. Copyright

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