PEDIATRIC SAFETY
| PATIENT SAFETY IN THE PEDIATRIC EMERGENCY DEPARTMENT —Joan E. Shook, MD, Professor of Pediatrics, Head, Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, and Chief Safety Officer and Medical Director of Emergency Medicine Service, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX |
| Case 1: boy, 8.5 yr of age; undergoing treatment for medulloblastoma; recently had resection; has ventriculoperitoneal shunt for residual hydrocephalus; presented with neck pain and emesis; torticollis on examination, with tenderness in sternocleidomastoid (SCM); neck discomfort more than just tenderness in SCM; computed tomography (CT) unchanged from previous studies; white blood cell count 22,000/µL, with 76% polymorphonuclear cells and 18% bands; on steroids; emergency department (ED) course—given ketorolac (Toradol) but still uncomfortable; decision to perform lumbar puncture made child extremely anxious; attending physician asked resident to give child diazepam 5 mg; 1 hr later, child somnolent with O2 saturation ≈70%; given flumazenil; chart revealed patient given intravenous (IV) lorazepam 5 mg |
| Scope of problem: in 1999, Institute of Medicine suggested that in United States, 44,000 to 98,000 pattents die annually due to medical errors; for each hospitalized person who dies, 5 to 10 suffer nonfatal nosocomial infections; patients in intensive care unit (ICU) average 1.7 errors per day; errors correlate with intensity of service; 2% to 7% of hospitalized patients have adverse drug event; thought that children 3 times more likely to suffer adverse drug events; failure to communicate root cause of 65% of serious events |
| Relevance to pediatrics: data show that risk higher in newborn period than at any other age; prevalence for older children similar to that for adults |
| Reasons for poor performance: collective inattention to patient safety (at system level); culture of ambiguity and work-arounds; consumer ignorance; reimbursement system that provides no incentive for safety; fragmented organizational structures; outmoded “mental model” for medical care; mental model of shame and blame—if individual patient does poorly, provider at fault and he or she should be blamed and reprimanded; logical consequence that provider will not make errors, or will never admit to errors made; systems appropriate focus for improvements; providers and patients should be equal members of health care delivery team; all members of team—should be able to identify and discuss system weaknesses without fear of sanction or repercussion; have responsibility to assist in improvement of health care system |
| Disclosure: patients and families—want full disclosure of all harmful errors; have mixed opinions about discussing near-misses; feel that disclosure enhances trust in caregivers; also want apology; definition—open and honest discussion about error; includes assurance that something being done to prevent recurrence and to ensure continuity of care in therapeutic relationship; provider must address issue of when he or she will be able to give more information; elements—what happened and why; implications for patient’s health; how problem will be corrected; how recurrences will be prevented; advance preparation essential; failure to disclose—undermines public’s trust in medicine; breach of professional ethics |
| Apology: acknowledgement of responsibility, coupled with expression of remorse; reasons for apologizing—restores patient’s and family’s self-respect and dignity, feelings of being cared for, and power in relationship; additional considerations—who should give apology (varies by institution); appropriate timing (as soon as possible after event); who should be notified and who should be present; reasons for failure of apology include insincerity |
| Analysis of case 1: while waiting for room, patient developed fever; given ceftriaxone; 15 hr after arriving in ED, blood culture showed gram-positive cocci; antibiotic changed; organism ultimately identified as group A streptococci; magnetic resonance imaging (MRI) showed pyomyositis of neck; patient received 14 days of IV antibiotics and did well; investigation—showed that resident misheard attending physician and wrote incorrect drug; patient cared for by nurse unfamiliar with ED; customary medication oversight absent |
| Case 2: infant, 8 days old, brought to ED for Rh incompatibility after being on home phototherapy; hemoglobin 3 g/dL; order written for 280 mL of packed red blood cells (RBCs) infused over 4 hr; blood arrived in large bag and transfusion began; patient transferred to neonatal ICU (NICU) 3 hr later; transfusion stopped; maximum hematocrit of child 63%; no exchange transfusion needed; child did well; analysis—blood bank form lacked standardized calculation table and place to note patient’s age and weight; blood for inpatient neonates delived in syringes, but blood delivered in bags to ED; no check of weight or age required in transfusion protocol |
| Analysis of errors: important that errors and near-misses be reported; modeled on aviation data which show that reporting increases ability to analyze and understand events and search for patterns; national data show that 42% of physicians have had adverse event and close to 100% have had adverse event that caused no harm; sources of adverse event data— document review; automated surveillance; monitoring of progress of patients to anticipate conditions that could lead to adverse events |
| Root cause analysis: performed in adverse event of sufficient severity or sufficient frequency; mandated by Joint Commission on Accreditation of Healthcare Organizations (JCAHO); definition—technique borrowed from engineering that identifies causal factors underlying variation in performance; focuses on systems and identifies potential improvements in system to decrease likelihood that same or similar event will occur in future; what root cause analysis is not— assignment of blame; morbidity and mortality review; clinical pathology conference; peer review; |
| Risks in pediatric setting: challenges in communication, complex diseases, pediatric patient size and physiology, drug-related issues, and multiple caregivers; trainees |
| Case 3: young woman, 18 yr of age, with history of cloacal extrophy; also has narcotic addiction, depression, and history of multiple urinary tract infections; came to ED accompanied by boyfriend and complaining of foul-smelling urine, emesis, and pain; in midst of methadone wean and having withdrawal symptoms; IV line placed and 10 mg methadone ordered; 30 min later, boyfriend screamed that patient not breathing; when physician arrived, patient apneic, blue, and having seizure; oral airway placed and bag-mask ventilation begun; 2 mg of naloxone administered; within seconds, patient sat up, pushed mask off her face, and asked for boyfriend; investigation—in speaker’s institution, methadone in 2 concentrations (1mg/mL in pharmacy and 10 mg/mL everywhere else); ED pharmacy borrowed medication from pediatric ICU (PICU); vials looked almost identical and patient received 10-fold overdose |
| Medication errors: review of medications administered at 36 JCAHO-accredited institutions on day shift showed 19% of medications delivered given in error; 7% of events potentially harmful; review of >10,000 pediatric medication orders showed almost 6% contained errors and of those, 20% potentially harmful; most serious errors related to 10-fold dosing; patients <2 yr of age and those admitted to ICU most at risk; goals— form “culture of safety” and organizational supports for safety processes |
| Comprehensive culture of safety: shared belief that although health care high-risk undertaking, delivery processes can be designed to make things safer and prevent harm; encourages reporting of events and near-misses to facilitate learning and redesign; requires environment where need for reporting and need to take disciplinary action balanced |
| Case 4: child 2 yr of age (born 22 wk prematurely), with mental retardation and cerebral palsy; had gastrostomy tube and fundoplication, cortical blindness, and seizure disorder; increased respiratory rate and fever; O2 saturation 84%; chest x- ray showed bilateral pneumonia; given O2 , IV fluids, and antibiotics; after 15 hr, admitted to hospital; multiple handoffs of care during ED stay; child taken to floor with O2 mask in place but not connected to tank; upon arrival, patient dusky (O2 saturation ≈60%); resuscitation initiated; patient intubated in elevator lobby and admitted to PICU but died next day |
| High-risk pediatric practice areas: pediatric ED; PICU; NICU; oncology areas; why ED dangerous— overcrowding; frequent interruptions in work processes; broad case mix; fatigue and stress; shift work with multiple handoffs of care; all personnel must watch each other and communicate across disciplinary divide; risks in pediatric ED—include weekends, deep night shifts, and presence of multiple trainees; patient’s perception of risk influences likelihood of returning and complying with recommendations |
| Investigation of case 4: handoffs; nurse who sent patient to floor failed to confirm that O2 working (performance issue); medical staff failed to assess child before transport; technician who transported child to floor had just come on shift and did not know patient; changes made as result—official signout of every patient by attending physician; establishment of formalized communication patterns with nurses; recommendations—standardize staffing levels, working hours, and work processes; build in redundancy and backup systems; improve teamwork |
| Team training and resource management: analogous to crew resource management in airline industry; staff taught consistent manner of communicating information; formalized team briefings; builds in acceptable ways for team members to challenge actions of others |
| TRUE PEDIATRIC EMERGENCIES —Scott A. Braunstein, MD, Attending Physician, Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA |
| Neonatal jaundice: elevated direct bilirubin—always abnormal; implies serious underlying disease; causes include infection and sepsis, biliary atresia, neonatal hepatitis, and inborn errors of metabolism; elevated indirect bilirubin— more common; physiologic jaundice of newborn most common cause (affects ≈60% of infants; bilirubin levels peak at 3 days of age and decrease by seventh to tenth day); breast milk jaundice (second most common cause; higher peak; can last weeks); hemolysis-related causes, eg, ABO incompatibility, hemoglobinopathies; (differentiated by Coombs’ test); kernicterus—caused by high bilirubin levels in neonate; staining of areas of brain, often basal ganglia and hippocampus, with bilirubin; results from lethargy and poor feeding to seizures, prominent neurologic sequelae, and death; risk factors—prematurity; hemolytic mechanism; low albumin (binds bilirubin and prevents it from crossing blood-brain barrier); sepsis or acidosis; indications for work-up—any jaundice in first 24 hr abnormal; direct hyperbilirubinemia (>20% of total bilirubin); total bilirubin >18 to 20 mg/dL; rise in bilirubin >5 mg/dL per day; jaundice persisting >1 wk in term infant or >2 wk in preterm infant; phototherapy—indications from American Academy of Pediatrics (AAP) clinical statement (2004); mainstay of treatment; exchange therapy indicated for severe cases and those refractory to phototherapy; threshold for treatment increases with number of days up to ≈5 days, then plateaus to allow for physiologic jaundice |
| Pyloric stenosis: most common cause of intestinal obstruction at >1 mo of age; 4 times more likely in boys than girls; risk factors family history and being firstborn; pathophysiology—hypertrophy of pylorus, causing obstruction and nonbilious (projectile) vomiting; infant still hungry and appears well between feedings; electrolytes show hypochloremic hypokalemic metabolic alkalosis (due to vomiting); on physical examination, may palpate olive-like mass (hypertrophied pylorus; pathognomonic); diagnosis usually made by ultrasonography; radiologist looks at length of pylorus (should be <16 mm), thickness of pyloric wall (should be <4 mm), and diameter of pylorus; treatment—IV fluids; correction of electrolytes; surgery (generally not urgent) |
| Midgut volvulus: 50% less common than pyloric stenosis; also more common in boys; occurs at younger age (generally <1 mo of age); pathophysiology—cecum and duodenum tacked down too close together during embryonic development; at birth, twisting around mesentery leads to volvulus, compression of superior mesenteric artery, and ischemia; patient presents with sudden bilious vomiting and abdominal distention and “shocky,” sick appearance; on abdominal series, classic “double bubble” sign seen (proximal bubble dilated stomach and distal bubble obstructed proximal duodenum); on upper gastrointestinal series, cecum in abnormal position (corkscrew bowel); treatment—urgent decompression by nasogastric tube; IV fluids; antibiotics; emergency surgery |
| Intussusception: usually occurs between 5 mo and 1 yr of age (up to 5 yr of age); pathophysiology—telescoping of one segment of bowel into another (classically at ileocecal valve but can happen anywhere); frequently follows viral-type illness; thought that inflammation of Peyer’s patches acts as lead point; mechanical obstruction and ischemia of bowel wall; triad of abdominal pain, vomiting, and bloody or “currant jelly” stools; lethargy fourth clinical factor; typically, pain comes in waves occurring every 30 min to 1 hr and lasting 15 min; on physical examination, “sausage” usually palpated on right side of abdomen; diagnostic and therapeutic treatment—barium or air enema; antibiotics and fluids; if unable to reduce, emergency surgery; if reduced, admit at least overnight because of 10% recurrence rate in first 24 hr |
| Henoch-Schönlein purpura: IgA-related vasculitis; typically occurs at ≈5 yr of age; triad of abdominal pain, palpable purpura on lower extremities, arthralgias, and microscopic hematuria; treated with outpatient supportive therapy; not dangerous; 5% of patients develop renal failure; severe cases treated with steroids and immunosuppressant combinations |
| Croup: laryngotracheobronchitis; most common cause of upper airway obstruction in children; peak age 2 yr, but can occur from 6 mo to 6 yr of age; pathophysiology—inflammation and edema of subglottic tissues around trachea at level of cricoid, causing upper airway narrowing; typically occurs in fall and winter; parainfluenza virus type 1 thought to cause >50% of cases; clinically, fever, rhinorrhea, and other symptoms of upper respiratory infection followed by barking cough and inspiratory stridor; scoring systems not useful; on anteroposterior x-ray of neck, classic “steeple sign” seen (narrowing of airway); treatment—no evidence that cool mist improves O2 levels or outcomes; steroids mainstay of treatment; study showed equal efficacy for oral dexamethasone at 0.15 mg/kg, 0.3 mg/kg, and 0.6 mg/kg; nebulized steroid (budesonide) has efficacy equal to high-dose dexamethasone; compared to dexamethasone, patients on prednisolone had higher rate of return to hospital; in patients with moderate croup, give steroids and racemic epinephrine; onset of action 10 min (concern with rebound stridor after wearing off); observe for 2 to 4 hr |
| Bacterial tracheitis: bacterial croup; acute onset; usually caused by Staphylococcus aureus; age group 3 yr to adolescence; pathophysiology—inflammation and sloughing of tracheal endothelium with thick secretions, causing obstruction; typically, patient with viral syndrome who suddenly becomes worse; treatment—antibiotics; bronchoscopy (diagnostic and therapeutic); if intubated, often on ventilator for long time; need high index of suspicion to diagnose |
| Foreign body aspiration: most common in toddlers; typically involves rounded food items; may hear localized wheezing; diagnosis usually made with bilateral decubitus x-rays that show hyperinflation of obstructed side; treatment— laryngoscope and Magill’s forceps to remove foreign body; bronchoscopy often needed; may need to push proximal obstructing foreign body down deeper into one of bronchi to enable aeration of one lung |
| Bronchiolitis: wheezing infant; lower airway reactive disease; usually at 2 to 6 mo of age; peaks during winter; respiratory syncytial virus (RSV) thought causative organism; spread by contact with secretions (not aerosolized); O2 saturation <95% on presentation single best predictor of severe episode; testing for RSV antigen not useful in ED; main concern apnea, which can lead to syncope or death; AAP clinical statement—mainstays of treatment supplemental O2 , keeping patient well hydrated, and preventing iatrogenic spread by handwashing; optional trial of α- or β-agonists; meta-analysis showed racemic epinephrine slightly better than β-agonist; if no improvement after 60 min or after few treatments, stop (no improvement expected); steroids, ribavirin, and antibiotics of no proven benefit and not recommended routinely; palivizumab (Synagis; monoclonal antibody against RSV) effective and recommended for premature infants and those with chronic lung or heart disease from birth; given at <6 mo of age; give monthly, starting in December, for 5 mo; risk factors for apnea include age <3 mo, prematurity, low O2 saturation at presentation, and comorbidities |
Suggested Reading
Frush KS: Medication errors in pediatric emergency care.developing a national standard? Ann Emerg Med 50:369, 2007; Gallagher TH et al: Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 289:1001, 2003; Kozer E et al: Medication errors in children. Pediatr Clin North Am 53:1155, 2006; Lazare A: Apology in medical practice: an emerging clinical skill. JAMA 296:1401, 2006; Marcin JP et al: Medication errors among acutely ill and injured children treated in rural emergency departments. Ann Emerg Med 50:361, 2007; Mazor KM et al: Health plan members' views about disclosure of medical errors. Ann Intern Med 140:409, 2004; McCollough M et al: Abdominal pain in children. Pediatr Clin North Am 53:107, 2006; Oakley E et al: Using video recording to identify management errors in pediatric trauma resuscitation. Pediatrics 117:658, 2006; Sharek PJ et al: The incidence of adverse events and medical error in pediatrics. Pediatr Clin North Am 53:1067, 2006; Vasavada P: Ultrasound evaluation of acute abdominal emergencies in infants and children. Radiol Clin North Am 42:445, 2004; Willwerth BM et al: Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med 48:441, 2006.
Educational Objectives
| The goals of this program are to improve patient safety in the pediatric emergency department and improve management of pediatric emergencies. After hearing and assimilating this program, the clinician will be better able to: |
 |
1. List the elements of a medical error disclosure. |
|
2. Utilize the categories of investigation involved in root cause analysis. |
|
3. Implement recommendations necessary to establish a culture of safety in the emergency department. |
|
4. Recognize the indications for work-up of neonatal jaundice. |
|
5. Diagnose and manage various respiratory and abdominal pediatric emergencies. |
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and the planning committee reported nothing to disclose.
Acknowledgements
Dr. Shook was recorded at Pediatric Emergency Medicine 2007, held April 10-14, 2007, in Lake Buena Vista, FL, and sponsored by Nemours. Dr. Braunstein was recorded at the 4th Annual Emergency Medicine Symposium, held December 1, 2006, in Los Angeles, CA, and sponsored by Cedars-Sinai Medical Center, Department of Emergency Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
|
