Errors detected during multidisciplinary work rounds
| Category I audit questions* | Errors detected per 100 patient days† | Total no of errors | No of days question audited |
|---|---|---|---|
| NICU, neonatal intensive care unit; CVC, central venous catheter; ND, not determined. | |||
| *Category I items: Median number of days the unit was audited for a given question = 7 (average unit census 19.5); average number of days the unit was audited for a given question = 7.1 (average unit census 19.5); range of number of days the unit was audited for a given question = 4–10 (average unit census 19.5). | |||
| †To calculate the number of errors per 100 patient days we divided the number of errors detected by a question during the study by the product of the average daily census (19.5) of the NICU and the number of days the question was audited. This number was multiplied by 100. | |||
| All patients rounded on were audited. | |||
| Blood/laboratory studies | |||
| Was a blood/laboratory test ordered and not sent? | 2.3 | 4 | 9 |
| Was a blood/laboratory test drawn or sent on the wrong patient? | 0.6 | 1 | 9 |
| Did a blood/laboratory test need to be repeated due to a procedural problem? | 4.5 | 7 | 8 |
| Was a blood/laboratory specimen sent unlabeled or mislabeled with the wrong patient’s name? | 0.6 | 1 | 8 |
| Radiology studies | |||
| Was a radiological procedure ordered and not done? | 1.5 | 2 | 7 |
| Did an x ray or other procedure need to be repeated due to a procedural problem? | 0.7 | 1 | 7 |
| Was a requisition for a radiological procedure mislabeled? | ND | ⩾1 | 4 |
| Delays in patient service | |||
| Was there a delay in informing parents of a “significant” clinical event or significant change in clinical status? | 1.7 | 3 | 9 |
| In the past 2 days, was a consultation ordered and not done? | 1.3 | 2 | 8 |
| Did a delay in reporting a laboratory test or radiology result affect clinical management? | 0 | 0 | 6 |
| Did a delay in responding to an alarm result in an adverse outcome? | 0 | 0 | 5 |
| Information transfer | |||
| Was important information that would affect the clinical management of a patient not transferred verbally or in writing? | 2.1 | 4 | 10 |
| Were x rays/tests to be done on your shift not reported? | 0 | 0 | 7 |
| Patient care equipment/medical devices | |||
| Was a patient accidentally extubated? | 1.9 | 3 | 8 |
| Did a ventilator malfunction? | 0 | 0 | 10 |
| Was a chest tube accidentally dislodged? | 0 | 0 | 9 |
| Did an alarm failure or malfunction cause a delay in treatment? | 0 | 0 | 5 |
| Was there an IV infiltrate that caused injury? | 4.1 | 4 | 5 |
| Did a CVC migrate or come out? | 0.7 | 1 | 7 |
| Patient transport | |||
| Did an adverse event occur while the patient was away from the NICU? | 0 | 0 | 5 |
| Pain | |||
| Were pain control measures during invasive procedures not used according to unit policy? | 1.0 | 1 | 5 |
| Pain not assessed before invasive procedures | 0 | 0 | 4 |
| Errors detected | ⩾35 | ||