Journal Information
Vol. 96. Issue 3.
Pages 267-270 (01 March 2022)
Vol. 96. Issue 3.
Pages 267-270 (01 March 2022)
Scientific Letter
Open Access
Desing of a risk map in a paediatric emergency department
Diseño de un mapa de riesgos en un servicio de urgencias pediátrico
Vanessa Arias Constantia,b,
Corresponding author

Corresponding author.
, Elisabet Rifé Escuderob, Victoria Trenchs Sainz de la Mazaa,b, Jose Manuel Blanco Gonzálezb, Carles Luaces Cubellsa,b
a Influencia del entorno en el bienestar del niño y del adolescente, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat (Barcelona), Spain
b Servicio de Urgencias de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat (Barcelona), Spain
Article information
Full Text
Download PDF
Tables (2)
Table 1. Classification of severity (S), occurrence/frequency (O) and detection (D).
Table 2. Failure modes with a risk priority number (RPN) greater than 30 (essential risk map).
Show moreShow less
Full Text
Dear Editor:

Patient safety is a perspective from which to understand health care without which the latter would be meaningless.1

In paediatric emergency departments (PEDs), the risk of adverse effects is high due to the particular characteristics of their patients.2 The clinical information paediatricians obtain from parents and medication dosages are individualised, which involves calculations that provide opportunities for error.

Traditionally, patient safety refers to event investigation and analysis, which is difficult to translate to learning and prevention of repeated errors. In Spain, several studies have been developed with this approach (ENEAS, APEAS, EARCAS, SYREC and EVADUR). They contribute to the detection of errors once they have already happened, so other, proactive tools need to be implemented, such as risk maps, to promote awareness of probable or demonstrated risks and harm in care delivery.3 The aim of our study was to describe our experience with the design and development of a risk map for our own care setting.

We developed the risk map using the Failure Modes and Effects Analysis (FMEA) approach.4 We started by defining the emergency care processes and subprocesses from arrival of the patient to the desk to discharge from the PED. We identified risks in a brainstorming process that involved a multidisciplinary team (paediatricians, nurses and security, laboratory, radiology, administrative and pharmacy staff) based on staff statements concerning 719 events (2012–2018) and the review of complaints and suggestions filed by families (635 in the period under study). We collected the data in a FMEA template, including the specific care process and subprocesses, the defined failure mode or risk, its causes, the type of effect and possible measures for control or improvement. We estimated the severity (S), probability of occurrence (O) and probability of detection (D) of the events (Table 1), rating each on a scale from 1 to 5. The ratings were established by consensus by all participating professionals. We stratified risk based on the risk priority number (RPN): RPN = S × O × D. The resulting numbers could range from 1 to 125, with higher values indicating greater priority. We developed the risk map prioritising the causes that corresponded to the highest RPNs for the purpose of developing improvement strategies (essential risk map).

Table 1.

Classification of severity (S), occurrence/frequency (O) and detection (D).

Severity  Criterion: failure mode based on impact on patient (S)  Ranking 
Minimum  Failure of small importance unlikely to cause any actual harm even if it reaches the patient 
Minor  Failure that may reach the patient and would not cause harm, but would require monitoring or intervention to ensure patient is not harmed 
Moderate  Failure that causes or contributes to temporary harm and requires or prolongs hospitalization or requires intervention 
Critical  Failure that causes or contributes to permanent harm or threatens the life of the patient, requiring intervention to save patients’ life 
Catastrophic  Failure that may cause permanent disability or death if it reaches the patient 
Occurrence  Criterion: probability of occurrence of failure mode (F)   
Infrequent/unlikely  Isolated failures in the specific process. It is probable in the life of the process, but unlikely to occur in years at a time 
Low  Failure that occurs infrequently in the process or similar processes (once a year) 
Moderate  Probable failure. The failure has occurred with relative frequency in the past in the specific process or similar processes (several times a year) 
High  Very probable failure. The failure is expected to occur frequently (every month) 
Very high  Nearly inevitable failure. The failure occurs very frequently, daily or weekly 
Detection  Criterion: likelihood of detection of failure mode (F)   
Almost certain  The failure is obvious. It is highly unlikely that it will not be detected by existing controls (95−100%) 
High  The failure, while obvious and easily detectable, could escape an initial check, but would certainly be detected later on (75−94%) 
Moderate  The failure is detectable and may not reach the patient. It may be detected in the late stages of the process (40−74%) 
Low  The failure is intrinsically difficult to detect with the protocols currently in place (6−39%) 
Unlikely  The failure cannot be detected. It is nearly certain to reach the patient (0−5%) 

In the initial round, we identified 7 urgent care processes (admission, triage, initial nursing care, medical care, diagnostic testing, treatment and discharge destination), 17 subprocesses, 60 potential failures or risks with 92 effects and 199 causes. The essential risk map ended up comprising 15 subprocesses with 19 effects with a RPN greater than 30 (Table 2).

Table 2.

Failure modes with a risk priority number (RPN) greater than 30 (essential risk map).

Failure mode  Risk  Preventive measures  RPN 
Delay in collection of patient data  Clinical worsening  Increase staff  48 
  Risk of infection  Implement use of bar code to read data  36 
Initial nursing care
Not performed by moving patient to the consultation area  Delay in treatment initiation  Implementation of patient arrival and triage protocol  36 
  Missing clinical information in health records    48 
Medical care
Delay in providing care to patient  Clinical worsening  Specific training  40 
  Patient discomfort    40 
Failure to detect allergies  Adverse drug reaction  Specific training  80 
Lack of medication reconciliation  Worsening of underlying disease  Pilot programme of medication reconciliation  48 
Poorly performed physical examination  Inadequate care  Supervision of physicians in training; mini-Clinical Evaluation Exercise  48 
Errors in diagnosis  Inadequate care  Supervision of physicians in training; mini-Clinical Evaluation Exercise  48 
Error in identification of samples and patients  Mixing up health records; inadequate care  Patient identification wristbands  36 
Problems in sample collection  Delay in necessary care  Training of nurses  36 
Imaging tests
Failure to perform test when indicated  Delay in necessary care  Supervision of physicians in training; mini-Clinical Evaluation Exercise  36 
Identification error  Patient receives unnecessary treatment  Patient identification wristbands  36 
Wrong dosage  Adverse drug reaction  Weight alarm  36 
Omission of treatment  Delay in necessary care    75 
Destination at discharge (admission to ward)
Patient without medical directions  Delay in treatment initiation  Create checklist for use before admission to ward / medication reconciliation  60 
Transfer of patient to ward under suboptimal conditions  Clinical worsening during transfer  Create checklist for use before admission to ward  48 
  Duplication of medical treatment  Documentation of discharge report in health records  48 

The proposed risk map reviews every care process in emergency care and allows their proactive analysis. To develop it, we used brainstorming and reactive analytics. We used brainstorming repeatedly in the FMEA4 as a proactive safety measure. Incident analysis is weaker for this purpose.5 An aspect worth highlighting was the incorporation of the information and feedback provided by families, given the importance of the experience of patients and families and their involvement in care processes.6

When we analysed the distribution of failures, causes and effects, we found the highest number of causes of error in medical care (which could be due to our centre being a university hospital that has physicians in training on staff), diagnostic tests (processes that are not performed in full within the PED and may involve several professionals and spaces) and treatment (calculation of doses for weight under stressful circumstances).

As for the abridged version of the risk map, we ought to highlight the failure to identify allergies, omissions of treatment and transfer of patients to the ward without adequate medical directions. Improvement measures have been implemented, such as staff training, improvements in electronic health records and use of a checklist before patient transfer. The implementation of measures to prevent these severe failures has resulted in the reduction of other errors of lesser impact.

Some of the limitations of the study are that it yielded a lengthy document, that its implementation would be costly, and that it may not be possible to extrapolate it to facilities of different characteristics.

To conclude, we ought to highlight that a risk map is a tool for proactive risk management. Its findings will help us assess our activity, identify problems and implement improvement measures.

Appendix A
Individuals that collaborated in the development of the risk map

Elisabet Rife Escudero, Gemma Bial Vellve, Isabel de Andrés Yagüe, Susana Ortiz Solsona, Mercedes Jabalera, Esther Álvarez Matesanz, Mercedes Gimeno Mayor, Eva Gargallo Burriel, Yolanda Fernández Santervas, David Muñoz Santanach, Cristina Parra Cotanda, Victoria Trenchs Sainz de la Maza, Jesús Velasco Rodríguez, Josep Munuera del Cerro, Omar Rodríguez Forner, Francisco José Cambra Lasaosa, María Mercedes Molina Carbonell, Carles Luaces Cubells and José Blanco González.

M. Tejedor Fernández, F.J. Montero Pérez, R. Miñarro del Moral, F. Gracia García, J.J. Roig García, A.M. García Moyano.
Diseño e implantación de un plan de segu-ridad del paciente en un servicio de urgencias de hospital: ¿cómo hacerlo?.
Emergencias, 25 (2013), pp. 218-227
E. Mojica, E. Izarzugaza, M. Gonzalez, E. Astobiza, J. Benito, S. Mintegi.
Elabora-tion of a risk map in a paediatric Emergency Department of a teaching hospital.
Emerg Med J, 33 (2016), pp. 684-689
S. Tomás Vecina, M.J. Bueno Domínguez, M. Chanovas Borrás, F. Roqueta Egea, Grupo de trabajo Mapa de Riesgos SEMES.
Diseño y validación de un mapa de riesgos para la mejoría de la seguridad del paciente en los servicio de urgencias hospitalarios.
Trauma Fund MAPFRE, 25 (2014), pp. 46-53
Institute for Healthcare Improvement and
Failure Modes and Effects Analysis (FMEA).
R.M. Rishoej, A.B. Almarsdóttir, H.T. Christesen, J. Hallas, L.J. Kjeldsen.
Medication errors in pediatric inpatients: a study based on a national mandatory reporting system.
Eur J Pediatr, 176 (2017), pp. 1697-1705
C. Parra, N. Carreras, A. Vergés, V. Trenchs, C. Luaces.
Patient experience in a Spanish pediatric emergency department.

Please cite this article as: Arias Constantí V, Rife Escudero E, Trenchs Sainz de la Maza V, Blanco González JM, Luaces Cubells C. Diseño de un mapa de riesgos en un servicio de urgencias pediátrico. An Pediatr. 2022;96:267–270.

Copyright © 2022. Asociación Española de Pediatría
Anales de Pediatría (English Edition)

Subscribe to our newsletter

Article options
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?