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Anatomy of a patient safety event: a pediatric patient safety taxonomy
  1. D M Woods1,
  2. J Johnson2,
  3. J L Holl3,
  4. M Mehra4,
  5. E J Thomas5,
  6. E S Ogata6,
  7. C Lannon7
  1. 1Institute for Healthcare Studies, Feinberg School of MedicineNorthwestern University, Chicago, IL, USA
  2. 2Department of Medicine, University of ChicagoChicago, IL, USA
  3. 3Institute for Healthcare Studies and Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Children’s Memorial HospitalChicago, IL, USA
  4. 4Feinberg School of MedicineNorthwestern University, Chicago, IL, USA
  5. 5Department of Medicine, University of Texas Medicial SchoolHonston, TX, USA
  6. 6Children’s Memorial HospitalChicago, IL, USA
  7. 7Center for Children’s Healthcare Improvement, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel HillChapel Hill, NC, USA
  1. Correspondence to:
 Dr D M Woods
 Northwestern University, Weibildt Hall, Chicago, IL 60611, USA; woods{at}


Background: Idiosyncratic terminology and frameworks in the study of patient safety have been tolerated but are increasingly problematic. Agreement on standard language and frameworks is needed for optimal improvement and dissemination of knowledge about patient safety.

Methods: Patient safety events were assessed using critical incident analysis, a method used to classify risks that has been more recently applied to medicine. Clinician interviews and clinician reports to a web based reporting system were used for analysis of hospital based and ambulatory care events, respectively. Events were classified independently by three investigators.

Results: A pediatric patient safety taxonomy, relevant to both hospital based and ambulatory pediatric care, was developed from the analysis of 122 hospital based and 144 ambulatory care events. It is composed of four main categories: (1) problem type; (2) domain of medicine; (3) contributing factors in the patient (child-specific), environment (latent conditions) and care providers (human factors); and (4) outcome or result of the event and level of harm. A classification of preventive mechanisms was also developed. Inter-rater reliability of classifications ranged from 72% to 86% for sub-categories of the taxonomy.

Conclusions: This patient safety taxonomy reflects the nature of events that occur in both pediatric hospital based and ambulatory care settings. It is flexible in its construction, permits analysis to begin at any point, and depicts the relationships and interactions of elements of an event.

  • ambulatory care
  • medical errors
  • paediatrics
  • classification
  • critical incident analysis

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  • This research was supported in part by a seed grant from the Children’s Memorial Institute for Evaluation and Research. Research for this paper was done while the first author was a National Research Service Award postdoctoral fellow at the Institute for Health Services Research and Policy Studies, at the Feinberg School of Medicine, Northwestern University under an institutional award from the Agency for Healthcare Research and Quality.

  • This research was performed under the approval of the Institutional Review Boards of Children’s Memorial Hospital and the University of Chicago.