TY - JOUR T1 - Why identifying adverse events in paediatric emergency care matters JF - BMJ Quality & Safety JO - BMJ Qual Saf SP - 776 LP - 778 DO - 10.1136/bmjqs-2022-014939 VL - 31 IS - 11 AU - Kenneth A Michelson AU - Richard T Griffey Y1 - 2022/11/01 UR - http://qualitysafety.bmj.com/content/31/11/776.abstract N2 - The emergency department (ED) abounds with hazards that might lead to adverse events (AEs). Clinicians must make frequent, high-consequence decisions with high diagnostic uncertainty as part of ad hoc teams taking care of patients not generally known to them.1 This occurs in the context of a sometimes chaotic environment with frequent interruptions, handoffs and shift changes. As a result, the ED tends to magnify cognitive biases that can result in AEs—particularly diagnostic AEs.2 This is especially problematic for children who account for 23 million ED visits in the USA annually and are particularly vulnerable to AEs. Children are developmentally less able to communicate specific symptoms and are evaluated in EDs with variable readiness to care for them.3 Yet, little is known about the occurrence and nature of AEs in paediatric ED patients.In this issue of BMJ Quality & Safety, Plint and colleagues4 sought to address this gap. They conducted a prospective observational study of children visiting nine Canadian paediatric EDs to determine whether an AE occurred within 3 weeks of a visit.5 AEs were defined as ‘any event resulting in unintended patient harm that was related to the care provided rather than to an underlying medical condition’. They found that 3% of visits were associated with an AE, of which 77% were judged to be preventable. The most common AEs related to management, diagnosis and medication. Although the large majority of AEs were minor, half prompted the need for subsequent care. Risk factors associated with a preventable AE were increasing age, history of chronic condition, increasing time to initial ED assessment and evaluation in the acute care area (rather than the ambulatory area).This study illuminates an underexplored area in paediatric emergency care: given its inherent hazards, how often do AEs happen? Plint … ER -