Adverse events in a paediatric intensive care unit: relationship to workload, skill mix and staff supervision.

Objectives: A systems approach proposes that hospital adverse events (AE) represent a failure of the organization rather than the individual, and are more likely when sub-optimal working conditions occur. We analysed AE using a systems approach to (a) investigate the association between AE occurrence and "latent" risk factors, which included temporal, workload, skill mix and supervision issues, and (b) document interactions between clinically related risk factors.

Design: Prospective observational study.