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Incident Reporting as A Quality Improvement Tool in Paediatric Resuscitations


 BACKGROUND: A code is called through locating for any child under 16 years of age who requires resuscitation in our hospital and a team of physicians, nurses and resuscitation officers attend these resuscitations. All clinicians involved in the resuscitation are sent a standardised questionnaire by the resuscitation office to identify issues during that resuscitation which may not be captured elsewhere. This feedback system was established to create a mechanism for anonymous feedback from all members of resuscitation teams.
 OBJECTIVES: The objective of this study was to identify the teams' perception of issues in clinical care and remedial actions that were implemented by the institution to address these gaps.
 DESIGN/METHODS: A retrospective review of all voluntary anonymous survey responses that were generated at our institution from January to December 2013 was conducted after Research Ethics Board review and approval. A narrative analysis was conducted by the Resuscitation Officersand a Paediatric Emergency Consultant to identify themes and categories.
 RESULTS: There were 56 medical and 49 trauma resuscitations occurred in 2013 of which all traumas (49) and 48 (86%) of medical resuscitations were in the emergency department There were fully or partially completed surveys available for 97 resuscitations that occurred in the emergency department during the study period. Major themes with positive comments included; the team lead from the emergency department and clear role identification during the resuscitations. Identified themes with concerns included providers’ knowledge gaps, process delays due to equipment issues and system issues. Knowledge gaps regarding drowning management, protocols for cardiopulmonary resuscitations, and lack of clarity regarding policies and procedures when a child is certified dead after resuscitation were identified. Equipment delays for paediatric resuscitation were due to absent batteries in laryngoscope, suction failure, lack of small cuffed endotracheal tubes in ED, inability to find oxygen saturation connectors, and lack of enteral syringes in resuscitation areas. The system issues that were identified included inadequate space in the resuscitation room, in-adequate number of lead aprons when there were more than one trauma case, specimen transport delays and delays in accessing paediatric sub-speciality services.
 CONCLUSION: Issues with resuscitations can be identified through anonymous feedback even when robust systems and processes are in place to ensure appropriate personnel and equipment are readily available at paediatric resuscitations. Our study identified provider, process and system issues in paediatric resuscitations which helped to identify strategies to improve service delivery.