August 16-17, 2010
Pregnancy and Perinatology (PP) Branch, Center for Developmental Biology and Perinatal Medicine (CDBPM), NICHD
Marriott Bethesda North, Bethesda, Maryland
Background: According to a report from the Institute of Medicine, To Err is Human, (2000), medical errors account for 44,000 to 98,000 deaths each year in the US. This rate is higher than deaths from motor vehicle accidents (43,458), breast cancer (42,300), and AIDS-related illnesses (16,526). The leading categories of adverse outcomes attributable to healthcare in the neonatal period include: health-care associated infections (HAI); medication errors (wrong drug, wrong dose, wrong interval, or wrong patient); laboratory errors (performance errors; reporting errors; specimen mix-ups); errors and complications due to procedures (e.g. cardiac perforation from intravenous central-line catheters; air-leak syndromes during assisted ventilation; errors due to wrong or missed diagnoses); and errors due insufficient, inadequate, or inappropriate record keeping and follow-up instructions. Nearly 33,000 newborn infants in the NICU each year suffer from HAI.
Despite a high prevalence, "patient safety" as a topic has received little attention in the setting of neonatal intensive care. Thus, the epidemiology, causes, consequences, and prevention of healthcare-related errors in the care of newborn infants have been poorly studied. There is an urgent need to conduct comprehensive evaluation of the science to understand systems-related factors that contribute to various categories of errors, and to conduct research into the individual, systems-level, and institutional-level interventions to prevent such errors.
This workshop is intended to fill in some of knowledge gaps in this topic. Experts from diverse specialties will address the following issues and propose a research agenda:
- The epidemiology of patient safety
- Why do errors occur? How do we recognize errors, and monitor and analyze them?
- Why human components fail; are they due to the limits of human cognition related to information processing, vigilance; and assumptions?
- What work-related factors contribute to (or decrease) tendency for errors (fatigue, interference, stress and anxiety; etc.)? How to optimize physical environment to prevent errors (safe workplace; safe patient care areas; facility layout).
- What are the best methods to manage information processing and data sharing efficiently with patient safety in mind?
- Patient-healthcare team interaction(s), including ethics of disclosure
- Educational needs and communication with the patient and/or family
- What are the research needs?
For More Information
Dr. Tonse Raju, PP Branch, CDBPM, NICHD
Tel: (301) 402-1872