Multiple Errors in Care Befall Hospitalized Children

DENVER — Harmful adverse events occur in hospitalized infants and children at alarming rates, according to a series of studies that go beyond incident reports to identify errors from patient charts.

When Dr. Paul Sharek and his associates used “trigger tools” to examine data in pediatric patient charts, they found the following:

▸ There were 11.1 adverse drug events per 100 admissions to 12 children's hospitals in the United States (Pediatrics 2008;121:e927-35).

▸ There were 74 adverse drug and nondrug events per 100 admissions to North American neonatal intensive care units, 56% of which were deemed preventable (Pediatrics 2006;118:1332-40).

▸ There were 1,488 errors in 734 patients admitted to pediatric intensive care units, averaging two harmful events per patient (in press).

“Basically, 1 out of every 4 days [of hospitalization], a child gets hurt,” Dr. Sharek said at a meeting on pediatric hospital medicine sponsored by the Society of Hospital Medicine, the Academic Pediatric Association, and the American Academy of Pediatrics.

“I thought this was earth-shattering news,” said Dr. Sharek of data collected for three studies of inpatient safety in pediatrics.

Historically, most studies of safety in pediatric inpatient care were based largely on incident reports, most often focusing on medication errors.

While Dr. Sharek said that such errors are estimated to result in more than 4,000 deaths and cost more than $1 billion a year, these officially documented mistakes barely “scratch the surface” of harmful events.

“The tip of the iceberg [analogy] is really relevant here,” said Dr. Sharek, medical director of quality management and chief clinical patient safety officer at Lucile Packard Children's Hospital of Stanford University in Palo Alto, Calif.

In looking at drug errors alone, the new methodology captured a health care reliability rate of 101 in properly delivering medications to hospitalized children. This rate equates to 1-2 failures out of 10 opportunities, a proportion considered to be “chaos” in industrial psychology studies.

Ten years into industrywide efforts to reduce hospital errors by focusing on “top offender” medical mistakes, “we probably haven't done squat,” said Dr. Sharek.

That's because targeting only high-end errors—an approach he likened to “putting out fires”—misses the critical day-to-day mistakes that cripple an institution's overall safety profile and compromise patient care.

Admittedly, not all errors are life threatening, but a shift in focus to overall systems that preclude mistakes will undoubtedly save many lives and millions of dollars, he said.

“It is time for us to think about a new paradigm,” he asserted.

By drawing on lessons from reliability science used in industry, medical professionals can shift the way errors are identified, examined, and corrected in a systematic way.

For example, instead of blaming a 10-fold overdose on a “dumb resident who was up all night,” reliability science encourages a broader look at conditions that allowed for the error and that leave open the possibility of the error being repeated.

“Look deeper … at multiple system points set up to fail,” he said.

This examination might include an analysis of workforce responsibilities, work hours, communication, drug labeling, pharmacy dispensing, and checks and balances within the system.

Organizations with high rates of reliability have in common a preoccupation with failure, large and small.

“Avoid complacency,” he said. “You look everywhere for failure. You can't sweep it under the rug.”

He cited as an example frequent mix-ups of stored mothers' breast milk given to infants at his institution. “It used to be that the nurses would say, 'What's the big deal?'” when such an error occurred, because mother's milk is frequently banked for use by other infants, anyway.

In fact, a system that accommodates errors is dysfunctional in a larger way, without standardized procedures in place to methodically prevent mistakes—be they in breast milk distribution or heparin administration.

Another way health care institutions can improve their safety margins is to incorporate a “stop the line” policy first introduced in factories, whereby any employee who sees an error is empowered to immediately identify it and ensure that it is corrected.

That means that a nurse or a surgical technician can put the brakes on “the world-class cardiothoracic surgeon who loves to suture chest tubes without gloves.”

Dr. Sharek reported no financial disclosures.

DENVER — Harmful adverse events occur in hospitalized infants and children at alarming rates, according to a series of studies that go beyond incident reports to identify errors from patient charts.

When Dr. Paul Sharek and his associates used “trigger tools” to examine data in pediatric patient charts, they found the following:

▸ There were 11.1 adverse drug events per 100 admissions to 12 children's hospitals in the United States (Pediatrics 2008;121:e927-35).

▸ There were 74 adverse drug and nondrug events per 100 admissions to North American neonatal intensive care units, 56% of which were deemed preventable (Pediatrics 2006;118:1332-40).

▸ There were 1,488 errors in 734 patients admitted to pediatric intensive care units, averaging two harmful events per patient (in press).

“Basically, 1 out of every 4 days [of hospitalization], a child gets hurt,” Dr. Sharek said at a meeting on pediatric hospital medicine sponsored by the Society of Hospital Medicine, the Academic Pediatric Association, and the American Academy of Pediatrics.

“I thought this was earth-shattering news,” said Dr. Sharek of data collected for three studies of inpatient safety in pediatrics.

Historically, most studies of safety in pediatric inpatient care were based largely on incident reports, most often focusing on medication errors.

While Dr. Sharek said that such errors are estimated to result in more than 4,000 deaths and cost more than $1 billion a year, these officially documented mistakes barely “scratch the surface” of harmful events.

“The tip of the iceberg [analogy] is really relevant here,” said Dr. Sharek, medical director of quality management and chief clinical patient safety officer at Lucile Packard Children's Hospital of Stanford University in Palo Alto, Calif.

In looking at drug errors alone, the new methodology captured a health care reliability rate of 101 in properly delivering medications to hospitalized children. This rate equates to 1-2 failures out of 10 opportunities, a proportion considered to be “chaos” in industrial psychology studies.

Ten years into industrywide efforts to reduce hospital errors by focusing on “top offender” medical mistakes, “we probably haven't done squat,” said Dr. Sharek.

That's because targeting only high-end errors—an approach he likened to “putting out fires”—misses the critical day-to-day mistakes that cripple an institution's overall safety profile and compromise patient care.

Admittedly, not all errors are life threatening, but a shift in focus to overall systems that preclude mistakes will undoubtedly save many lives and millions of dollars, he said.

“It is time for us to think about a new paradigm,” he asserted.

By drawing on lessons from reliability science used in industry, medical professionals can shift the way errors are identified, examined, and corrected in a systematic way.

For example, instead of blaming a 10-fold overdose on a “dumb resident who was up all night,” reliability science encourages a broader look at conditions that allowed for the error and that leave open the possibility of the error being repeated.

“Look deeper … at multiple system points set up to fail,” he said.

This examination might include an analysis of workforce responsibilities, work hours, communication, drug labeling, pharmacy dispensing, and checks and balances within the system.

Organizations with high rates of reliability have in common a preoccupation with failure, large and small.

“Avoid complacency,” he said. “You look everywhere for failure. You can't sweep it under the rug.”

He cited as an example frequent mix-ups of stored mothers' breast milk given to infants at his institution. “It used to be that the nurses would say, 'What's the big deal?'” when such an error occurred, because mother's milk is frequently banked for use by other infants, anyway.

In fact, a system that accommodates errors is dysfunctional in a larger way, without standardized procedures in place to methodically prevent mistakes—be they in breast milk distribution or heparin administration.

Another way health care institutions can improve their safety margins is to incorporate a “stop the line” policy first introduced in factories, whereby any employee who sees an error is empowered to immediately identify it and ensure that it is corrected.

That means that a nurse or a surgical technician can put the brakes on “the world-class cardiothoracic surgeon who loves to suture chest tubes without gloves.”

Dr. Sharek reported no financial disclosures.

DENVER — Harmful adverse events occur in hospitalized infants and children at alarming rates, according to a series of studies that go beyond incident reports to identify errors from patient charts.

When Dr. Paul Sharek and his associates used “trigger tools” to examine data in pediatric patient charts, they found the following:

▸ There were 11.1 adverse drug events per 100 admissions to 12 children's hospitals in the United States (Pediatrics 2008;121:e927-35).

▸ There were 74 adverse drug and nondrug events per 100 admissions to North American neonatal intensive care units, 56% of which were deemed preventable (Pediatrics 2006;118:1332-40).

▸ There were 1,488 errors in 734 patients admitted to pediatric intensive care units, averaging two harmful events per patient (in press).

“Basically, 1 out of every 4 days [of hospitalization], a child gets hurt,” Dr. Sharek said at a meeting on pediatric hospital medicine sponsored by the Society of Hospital Medicine, the Academic Pediatric Association, and the American Academy of Pediatrics.

“I thought this was earth-shattering news,” said Dr. Sharek of data collected for three studies of inpatient safety in pediatrics.

Historically, most studies of safety in pediatric inpatient care were based largely on incident reports, most often focusing on medication errors.

While Dr. Sharek said that such errors are estimated to result in more than 4,000 deaths and cost more than $1 billion a year, these officially documented mistakes barely “scratch the surface” of harmful events.

“The tip of the iceberg [analogy] is really relevant here,” said Dr. Sharek, medical director of quality management and chief clinical patient safety officer at Lucile Packard Children's Hospital of Stanford University in Palo Alto, Calif.

In looking at drug errors alone, the new methodology captured a health care reliability rate of 101 in properly delivering medications to hospitalized children. This rate equates to 1-2 failures out of 10 opportunities, a proportion considered to be “chaos” in industrial psychology studies.

Ten years into industrywide efforts to reduce hospital errors by focusing on “top offender” medical mistakes, “we probably haven't done squat,” said Dr. Sharek.

That's because targeting only high-end errors—an approach he likened to “putting out fires”—misses the critical day-to-day mistakes that cripple an institution's overall safety profile and compromise patient care.

Admittedly, not all errors are life threatening, but a shift in focus to overall systems that preclude mistakes will undoubtedly save many lives and millions of dollars, he said.

“It is time for us to think about a new paradigm,” he asserted.

By drawing on lessons from reliability science used in industry, medical professionals can shift the way errors are identified, examined, and corrected in a systematic way.

For example, instead of blaming a 10-fold overdose on a “dumb resident who was up all night,” reliability science encourages a broader look at conditions that allowed for the error and that leave open the possibility of the error being repeated.

“Look deeper … at multiple system points set up to fail,” he said.

This examination might include an analysis of workforce responsibilities, work hours, communication, drug labeling, pharmacy dispensing, and checks and balances within the system.

Organizations with high rates of reliability have in common a preoccupation with failure, large and small.

“Avoid complacency,” he said. “You look everywhere for failure. You can't sweep it under the rug.”

He cited as an example frequent mix-ups of stored mothers' breast milk given to infants at his institution. “It used to be that the nurses would say, 'What's the big deal?'” when such an error occurred, because mother's milk is frequently banked for use by other infants, anyway.

In fact, a system that accommodates errors is dysfunctional in a larger way, without standardized procedures in place to methodically prevent mistakes—be they in breast milk distribution or heparin administration.

Another way health care institutions can improve their safety margins is to incorporate a “stop the line” policy first introduced in factories, whereby any employee who sees an error is empowered to immediately identify it and ensure that it is corrected.

That means that a nurse or a surgical technician can put the brakes on “the world-class cardiothoracic surgeon who loves to suture chest tubes without gloves.”

Dr. Sharek reported no financial disclosures.