Seattle Children’s Serious Reportable Events Occurring Between 2004-2010

Adverse events are defined as episodes of care in which a patient is harmed, or is at risk for harm, based on medical treatment, rather than on their underlying disease. Adverse events may or may not be associated with a medical error.

Keeping our patients safe is central to everything we do at Seattle Children’s Hospital.

The Washington State Department of Health requires health care facilities to report Serious Reportable Events as defined by the National Quality Forum. There are 28 types of serious reportable events which may result in patient death or serious disability.

Our goal is to eliminate all adverse health events and medical errors. However, to reach this goal we need accurate data about the number of adverse events we have each year. To that end, we have implemented a culture of safety which encourages staff to report errors. This open communication allows us to accept accountability for errors, identify what went wrong and implement new safety measures to prevent them from happening again. We also support staff in reporting “close calls” – situations where an error was detected before it reached a patient – so that we can learn from those, as well. We also listen to our patients and their families and involve them in the design and implementation of safety improvements.

Every day we move closer to our goal of zero errors while our staff remains focused on keeping our patients safe.

Below are descriptions of serious reportable events that have occurred at Children’s over the last six years (2004 – 2010).

Surgery performed on the wrong body part (1)
This incident involved a therapeutic injection to the incorrect leg for a patient’s musculoskeletal problem. This necessitated a second injection on the correct side.

Unintended retention of a foreign object in a patient after surgery or other procedure (1)
In the process of placing a large intravenous line, the guide-wire was inadvertently left in the patient at the end of the procedure. The guide-wire was removed without problem several hours later.

Device related Death or Serious Disability (1)
A feeding tube perforated the intestinal wall of a patient with complex congenital heart issues; leading to the death of the patient.

Medication Error resulting in Death or Serious Disability (2)
We prescribed and dispensed a high-dose fentanyl patch for outpatient post-operative pain control to a teenager with special needs who could not tolerate pills or liquid medicines. The patient died at home on the night of surgery, from an inadvertent narcotics overdose.
An infant who was profoundly fragile received ten times the intended dose of calcium chloride and several days later succumbed to complications from the overdose.

Stage 3 or 4 pressure ulcer acquired after admission (10)
Ten patients developed Stage 3 or 4 pressure ulcers over the last five years. These ulcers occurred in critically ill patients who could not be easily repositioned to relieve pressure points on their skin, and in other critically ill children around the site of life-saving medical devices. We have made several changes in the way that we provide care in an attempt to prevent further pressure ulcers at Children’s.

Fall Resulting in Death or Serious Disability (1)
An infant with a chronic medical condition fell from his crib when the rail released from the “up” position as the child pulled to a standing position. The patient recovered fully.

Patient Abduction (1)
An infant with a chronic health condition was abducted from the hospital by their mother. The patient was readmitted to the hospital a few days later, received treatment and was released.

Sexual Assault (2)
A teen patient was allegedly assaulted by the parent-assigned caregiver who was responsible for staying with the patient overnight. Hospital staff reported the incident to the appropriate authorities.
A teen patient was allegedly assaulted by another patient while staying in the Inpatient Psychiatric Unit. Hospital staff reported the incident to the appropriate authorities and implemented additional safety procedures.

Physical Assault (1)
A teen patient was allegedly assaulted by another teen patient. Hospital staff reported the incident to the appropriate authorities.

About Seattle Children’s

Seattle Children’s Hospital, Foundation and Research Institute together deliver superior patient care, advance new discoveries and treatments through pediatric research, and raise funds to create better futures for patients. Consistently ranked as one of the top 10 children’s hospitals in the country by U.S. News & World Report, Seattle Children’s Hospital specializes in meeting the unique physical, emotional and developmental needs of children from infancy through young adulthood. Through the collaboration of physicians in nearly 60 pediatric subspecialties, Seattle Children’s Hospital provides inpatient, outpatient, diagnostic, surgical, rehabilitative, behavioral, and emergency and outreach services to families from around the world.

Located in downtown Seattle’s biotech corridor, Seattle Children’s Research Institute is pushing the boundaries of medical research to find cures for pediatric diseases and improve outcomes for children all over the world. Internationally recognized investigators and staff at the research institute are advancing new discoveries in cancer, genetics, immunology, pathology, infectious disease, injury prevention, bioethics and much more.

Seattle Children’s Hospital and Research Foundation and Seattle Children’s Hospital Guild Association work together to gather community support and raise funds for uncompensated care, clinical care and research. The foundation receives nearly 80,000 gifts each year, from lemonade stand proceeds to corporate sponsorships. Seattle Children’s Hospital Guild Association is the largest all-volunteer fundraising network for any hospital in the country, serving as the umbrella organization for 450 groups of people who turn an activity they love into a fundraiser. Support from the foundation and guild association makes it possible for Seattle Children’s care and research teams to improve the health and well-being of all kids.

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