Pediatric Patient Safety

In 1999, the Institute of Medicine (IOM) published the report "To Err is Human: Building a Safer Health System" outlining the significance of patient safety errors and the resulting harm of these errors.  The report states that “at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented.

Patient safety errors occur over a continuum of healthcare services, from the prehospital setting to the pharmacy; from the bedside to the home.  They occur for many reasons from miscommunications between healthcare teams to miscommunication between a healthcare provider and their patient. 

The following toolbox identifies resources for healthcare providers, families, and individuals interested in pediatric patient safety. Examples of model pediatric patient safety programs are also included.

HEALTHCARE PROVIDER RESOURCES

• Making Health Care Safer: A Critical Analysis of Patient Safety Practices. This resource was compiled by the Evidence Based Practice Center at the University of California – San Francisco/Stanford University for the Agency for Healthcare Research and Quality. The report focuses on the analysis of systems and practices that can improve patient safety, as opposed to focusing on the epidemiology of errors. The data indicates that there are 11 key practices which were strongly correlated with the improvement of patient safety. Please note that this document is 672 pages. Pertinent sections include: Section A: Adverse Drug Events (ADEs), pages 58-117; Section D: Safety Practices for Hospitalized or Institutionalized Elders, pages 280-300; Section F: Organization, Structure, and Culture, pages 411-457; and Section G: Systems Issues and Human Factors, pages 458-543. Also see: Promoting and Implementing Safety Practices, pages 573 – 610 and Analyzing the Practices, pages 611-648.

• Safer Health Care for Kids: Preventing Medical Errors in Pediatric Health Care Settings. The Safer Health Care for Kids program features a series of one-hour web-based seminars, or Webinars, on various topics within pediatric patient safety. Users can participate from the comfort of their office or home, and learn new strategies that can be immediately put into practice to prevent medical errors. Take advantage of this unique opportunity to learn more about preventing medical errors, and earn CME credit from office or home. There is no fee to participate, but pre-registration is required.

• Things that Work: Hot Topics in Pediatric Patient Safety (A Series of Conference Calls). In 2004, the American Academy of Pediatrics brought together a Patient Safety Advisory Group to consider how the Academy could provide leadership and support to make care safer for children and families. One of the suggestions was a listserv to enable those involved in patient safety to learn from one another. Another idea was a series of conference calls, "Things That Work," to share best practices with colleagues. The Advisory Group chose implementation of a safety bundle, safety walkrounds, and medication reconciliation as the first three topics for these calls. Participants were able to access the presenter's PowerPoint presentations, ask questions during the call, and continue the discussion with colleagues following each call via the moderated listserv. Access this link to sign up for the listserv and to access archived PowerPoint and audio files from each conference call.

• Medical Errors and Patient Safety. Duke University has compiled an extensive list of website resources on patient safety, including government and non-government sites. Each entry includes a brief description of the type of information to be found within each website.

• Pediatric Pharmacy Medication Safety Guidelines Seen As Important Step In Reducing Medication Errors. The Institute for Safe Medication Practices and the Pediatric Pharmacy Advocacy Group collaborated to produce the nation’s first set of guidelines to reduce pediatric medication errors. These guidelines are designed to improve medication safety practices in children’s hospitals, general acute care hospitals that admit pediatric patients, as well as ambulatory pediatric clinics..

• Pride, Prejudice, and Pediatric Sedation: A Multispecialty Evaluation of the State of the Art. This report on pediatric sedation marks the second in a series of workshops on patient safety convened by the National Patient Safety Foundation. The first workshop, sponsored by the NPSF, the Agency for Healthcare Research and Quality, and the Department of Veterans Affairs, led to the report “A Tale of Two Stories."

• My Medication List Provider Toolkit. The "My Medicine List" Provider Toolkit supports a national initiative intended to build public awareness of the need for patients to take an active role in managing their medications. The initiative’s goal is for every person to maintain an up-to-date list of every medication he or she is using and to share it with his or her health care provider during each and every visit. The Provider Toolkit offers healthcare providers several downloadable documents (newsletters, posters, brochures) to help promote the initiative's goal among target audiences.

• Nine Patient Safety Solutions. In 2005, the World Health Organization designated the Joint Commission and Joint Commission International as the WHO Collaborating Centre for Patient Safety Solutions. In 2007, the Centre released Nine Patient Safety Solutions. The basic purpose of the solutions is to guide the re-design of care processes to prevent inevitable human errors from actually reaching patients. An individual solution will present the problem, the strength of evidence supporting the solution, potential barriers to adoption, risks of unintended consequences created by the solution, patient and family roles in the solution, and references and other resources. Issues addressed include: look-alike, sound-alike medication names, patient identification errors, communication during patient hand-overs, performance of correct procedure at correct body site, control of concentrated electrolyte solutions, assuring medication accuracy at transitions in care, avoiding catheter and tubing mis-connections, single use of injection devices, and improved hand hygiene to prevent health care-associated infection.

EXAMPLE PRACTICES

• The Josie King Patient Safety Program at Johns Hopkins Childrens Center . The Josie King Pediatric Patient Safety Program at the Johns Hopkins Children’s Center is a first in many senses of the word. It was the first patient safety initiative funded by the Josie King Foundation in partnership with Johns Hopkins; the first formal program the Johns Hopkins Hospital used to improve patient safety after Josie's death; and the first of its kind in the country. See "Josie King Foundation" (listed below) for more information on Josie's story.

• Making Patient Safety the Centerpiece of Medical Liability Reform. This article discusses implementation of a MEDiC model (Medication Error Disclosure and Compensation Bill). This would include establishment of a National Patient Safety Database upon which analysis would be conducted to develop policy and practice recommendations.

• University of Pittsburgh Medical Center Shadyside's Condition H. This model pediatric safety program was developed as a result of the tragic death of 18-month-old Josie King. Its primary purpose is to meet the needs of patients and families in emergency situations. Either a patient or family can call for a Condition H team, consisting of an internal medicine house physician, patient relations coordinator, administrative nursing coordinator, and floor staff.

FAMILY AND CAREGIVER RESOURCES

Josie King Foundation

• Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe. In Josie's Story Sorrel King writes about her 18-month-old daughter Josie, the medical errors that led to Josie's death, the family's struggles to deal with their grief, Sorrel's foray into the health care industry as a patient safety advocate, and the safety improvements that have come about in Josie's memory. (Book)

• Speak Up For Safety: A Guide for Patients and Families. This fact sheet outlines six steps patients should take to work effectively and safely with their health care providers. Other valuable resources are available within the section Patient Safety Resources on the university's website.

• MyMedicationList.com. My Medicine List is an initiative intended to build public awareness of the need for patients to take an active role in managing their medications. The initiative’s goal is for every person to maintain an up-to-date list of every medication he or she is using and to share it with his or her health care provider during each and every visit. This site offers several downloadable "sample" medication checklist forms in both English and Spanish. Also included is a free application for your iPhone or iPod Touch that allows patients to manage and reference information about their medicines through an informative database.