Implementation of Improvements Based on the Analysis of Severe Adverse Events in Pediatric Patients

Introduction: Health systems currently present a great degree of complexity, which provides risks to patients related healthcare, and the possibility incidents with or without harm. Patient safety culture highlights need investigate, analyze, mitigate reduce patient. Medication errors have high potential do harm in pediatric hospital routines most them are preventable. The objective this study was describe severe drug-related adverse event root cause analysis implemented improvements. Methods: A 3-month-old patient undergoing therapeutic cardiac catheterization at another presented cardiorespiratory arrest post-procedure progression after returning origin; case events medication use pediatrics. Root performed using London Protocol. Brainstorming conducted main improvements be proposed institution. Results: Improvements were identified various processes, such as transport, drug dispensing, administration. made it possible select processes departments involved detect factors event. These changes monitored, five years indicators show that they become consolidated. Conclusions: explanation shows how service can review workflows implement prevent further damage through an