• Rahul K Shah, Lina Lander, Peter Forbes, Kathy Jenkins, Gerald B Healy, and David W Roberson.
• Division of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine, Washington, DC 20010, USA. rshah@cnmc.org
• Laryngoscope. 2009 May 1; 119 (5): 871-9.

ObjectivesStudies of medical error demonstrate that errors and adverse events (AEs) are common in hospitals. There are little data of errors on pediatric surgical services.MethodsWe retrospectively reviewed 50 randomly selected inpatient admissions to the otolaryngology service at a tertiary care children's hospital. We used a "zero-defect" paradigm, recording any error or adverse event-from minor errors such as illegible notes to more significant errors such as mismanagement resulting in a bleeding emergency.ResultsA total of 553 errors/AEs were identified in 50 admissions. Most (449) were charting or record-keeping deficiencies. Minor AEs (n = 26) and moderate AEs (n = 8) were present in 38% of admissions; there were no major AEs or permanent morbidity. Medication-related errors occurred in 22% of admissions, but only two resulted in minor AEs. There was a positive correlation between minor errors and AEs; however, this was not statistically significant.ConclusionsMultiple errors occurred in every inpatient pediatric otolaryngology admission; however, only 26 minor and eight moderate AEs were identified. The rate of errors per 1,000 hospital days (6,356 per 1,000 days) is higher than previously reported in voluntary reporting studies, possibly due to our methodology of physician review with a "zero-defect" standard. Trends in the data suggest that the presence of small errors may be associated with the risk of adverse events. Although labor-intensive, physician chart review is a valuable tool for identifying areas for improvement. Although small errors were common, there were few harms and no major morbidity.

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