Preventable adverse events in infants hospitalized with bronchiolitis.

Objective: To determine the incidence of preventable adverse events (AEs) and near misses (NMs) among infants hospitalized for bronchiolitis at a pediatric tertiary care hospital and the impact of these errors on hospital length of stay (LOS).

Methods: We studied 143 infants with bronchiolitis, ages 0 to 12 months, admitted from December 2002 to April 2003. Using prospective chart review and staff reports, we captured medical errors and AEs. Each event was classified as a (1) preventable AE, (2) nonpreventable AE, (3) intercepted NM, (4) nonintercepted NM, or (5) error with little or no potential for harm.

Results: Of 143 patients, 15 (10%) suffered an AE or NM. The incidence of preventable AEs was 10 per 100 admissions. We found a higher incidence of preventable AEs and NMs among critically ill patients (CIPs) compared with non-CIPs (68 vs 5 per 100 admissions, respectively), making the absolute risk of an AE or NM 14 times more likely in CIPs. Mean LOS was significantly longer for CIPs with at least 1 AE (9.1 +/- 8.8 days) than for CIPs without AEs (2.9 +/- 1.5 days). Mean LOS was not significantly different between non-CIPs who did (3.8 +/- 2.6 days) and did not (4.2 +/- 5.0 days) experience an AE.

Conclusions: Preventable AEs occur frequently among patients admitted for bronchiolitis, especially those who are critically ill. CIPs who suffer AEs during their hospitalization have longer hospital LOSs. Future studies should investigate error-prevention strategies with a focus on those patients with severe disease.