Table 2.
Examples of Errors and Adverse Events (AEs) by Reporting Source
| Error | AE |
|---|---|
| Family-Report Only | |
| Toddler with Kawasaki disease whose diagnosis of pleural effusion and pulmonary edema and treatment with furosemide was delayed by 12 h despite parent reporting rapid breathing and an unusual sound coming from the chest much earlier in the day. | Infant with bronchiolitis requiring intensive care admission for high flow nasal cannula who, on transfer back to the unit, was found by mother to have swaddler wrapped around her neck, vomiting, choking, and having difficulty breathing. Nurse did not suction the patient as requested by mother. |
| Clinician-Reported Only | |
| Teenaged patient with cystic fibrosis exacerbation admitted with elevated creatinine level who received a bolus of D5 NS + 20KCl despite nurse raising concerns with overnight resident that the patient had an elevated creatinine level and that the nurse had never administered this solution as a bolus before. | School-aged child with a metabolic disorder admitted for pancreatitis whose pain medication was delayed because an inappropriate rate of hydromorphone was ordered for the patient-controlled analgesia (PCA). |
| Reported by Both Family and Clinician | |
| Teenaged patient with inflammatory bowel disease on ketamine drip for pain control whose pump settings were incorrectly entered, resulting in patient receiving 3-fold the appropriate rate overnight. | Toddler admitted with fever and dehydration in the setting of Streptococcus, adenovirus, and coronavirus infection who experienced a 10-h delay in ordering maintenance IV fluids after parent alerted nurse about decreased oral intake and urination. Later that evening, patient experienced an IV infiltrate, after which there was another 10-h delay before IV fluids were restarted. This resulted in symptomatic dehydration, including tachycardia and dry mucus membranes, requiring need for additional IV fluid boluses. |
| Medical Record Review Only | |
| Teenaged patient with migraines admitted for dihydroergotamine infusion who was ordered for an incorrect dose of medication by overnight resident, who had not examined the patient or conferred with neurology. Dose was corrected before reaching patient. | Neonate admitted with a brief resolved unexplained event (BRUE) and cough in the setting of rhinovirus and respiratory syncytial virus infection who began to worsen and have desaturations and apneas. A chest radiograph was ordered (but not obtained), and the patient was transferred to the ICU for 4 d. Two d after being transferred from the ICU back to the general pediatric unit, the patient again developed apnea and desaturations, prompting septic workup and a chest radiograph, which revealed a right upper lobe pneumonia, for which the patient was subsequently treated with IV antibiotics. |
| Hospital Incident Report Only | |
| NA | Toddler with Kawasaki disease who fell and hit head during playtime. Patient required additional monitoring for changes in mental status. |
Abbreviations: D5 NS + 20KCL, potassium chloride in 5% dextrose and sodium chloride injection; ICU, intensive care unit; IV, intravenous; NA, not applicable.