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Eur J Pediatr. 2014 Apr;173(4):503-8. doi: 10.1007/s00431-013-2168-3. Epub 2013 Nov 16.

Addressing the taboo of medical error through IGBOs: I got burnt once!

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1
Department of Neonatology, Cork University Maternity Hospital, Wilton, Cork, Ireland.

Abstract

BACKGROUND:

An I Got Burnt Once (IGBO) is a near-miss or actual clinical event, related to patient safety, that leaves a lasting impact on the health professional (HP) involved. The purpose of this study was to collect and categorize IGBOs from a variety of pediatric HPs and to determine whether the individual's clinical practice was altered as a result.

METHODS:

Semistructured interviews involved recollection of an IGBO and subsequent changes in clinical practice. The IGBOs were classified into one of the seven Canadian Medical Education Directives for Specialists (CanMEDS) roles and outcome of the event.

RESULTS:

Of the 38 pediatric HPs approached (25 doctors and 13 female nurses), 35 recalled an IGBO. Most (74 %) were classified to the CanMEDS Medical Expert role (with subcategorization into diagnostics (37 %), treatment (34 %), and clinical management (31 %) followed by communicator (14 %) and collaborator (12 %) roles). Half (55 %) of the respondents considered the IGBO event to be potentially life threatening event to the patient, resulting in no harm (63 %), disability (14 %), and fatality in 17 % of the cases. Most respondents (92 %) stated that IGBOs affected their medical practice for months and sometimes years after the event.

CONCLUSIONS:

Most practitioners can recall an IGBO in their clinical practice. IGBOs may be a potential source of medical risk avoidance and reduction strategies, and worthy of further investigation by "deep dives" or root cause analysis.

PMID:
24240665
DOI:
10.1007/s00431-013-2168-3
[Indexed for MEDLINE]
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