Establishing Effective and Sustainable Pediatric Emergency Department Adverse Event Review Process

Background and Purpose: Preventable adverse events lead to significant patient morbidity and mortality. Multiple factors associated with acute care delivery, including chaotic environment, shift work, frequent hand offs, and interruptions, may contribute to preventable adverse events. Consistent reporting and review of adverse events and near misses may help identify and correct underlying causes. Our objective was to create a sustainable and effective adverse event review system in pediatric emergency network system. We aimed to establish a sustainable (at least 80% of sessions with 4-12 cases) and effective (at least 1 action item per session) standardized Emergency Department (ED) and Urgent Care (UC) Case …