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 and potential harm of patient safety errors in healthcare settings.  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 environment to the pharmacy, from the bedside to the home.  They occur for many reasons, from miscommunications within and among healthcare teams, to misunderstandings between providers and patients.

The following toolbox identifies resources for healthcare providers, families, and individuals interested in pediatric patient safety. Examples of model pediatric patient safety programs, as well as a pre-populated PubMed journal article search string, are also included.



HEALTHCARE PROVIDER RESOURCES

EMSC National Resource Center

  • iPEMS Podcast Series.  The EMSC National Resource Center (NRC), in collaboration with the Alliance for Pediatric Emergency Medication Safety, has produced a series of podcasts called iPEMS. These multimedia podcasts target medical students, residents, and fellowship trainees and focus on three primary objectives: (1) to educate trainees about pediatric medication safety issues in the emergency setting; (2) to describe potential solutions to improve medication safety; and (3) to equip trainees with the tools to implement a quality improvement initiative in their training program.

More details about this and other provider resources

EXAMPLE PRACTICES: Model Programs

Illinois EMSC

  • The Illinois EMSC Program uses a Continuous Quality Improvement (CQI) approach to improve the quality (and corresponding safety) of care within the state’s pediatric emergency and critical care system.  The program has assisted in the development of pediatric quality improvement committees within each of the eleven EMS regions to enhance prehospital and emergency department quality improvement activities.

More details about this and other example practices

DATABASE SEARCHES

National Library of Medicine PubMed Journal Article Database

PubMed Link doesn't work? Try PubMed Troubleshooting

Family & Caregiver Resources

FamilyDoctor.org

  • Medical Errors: Tips to Help Prevent Them. This web resource from FamilyDoctor.org empowers patients to take an active role in reducing the potential for healthcare errors by communicating with their healthcare team, asking appropriate questions, learning more about recommended treatments, and taking responsibility for their healthcare. (December 2009)

More details about this and other family and caregiver resources


HEALTHCARE PROVIDER RESOURCES

EMSC National Resource Center

  • iPEMS Podcast Series.  The EMSC National Resource Center (NRC), in collaboration with the Alliance for Pediatric Emergency Medication Safety, has produced a series of podcasts called iPEMS. These multimedia podcasts target medical students, residents, and fellowship trainees and focus on three primary objectives: (1) to educate trainees about pediatric medication safety issues in the emergency setting; (2) to describe potential solutions to improve medication safety; and (3) to equip trainees with the tools to implement a quality improvement initiative in their training program. (Accessed January 2014)

Agency for Healthcare Research and Quality

  • Patient Safety Network. This resource contains a comprehensive listing of patient safety journal articles, books, and toolkits, as well as primers addressing critical patient safety topics such as Medication Reconciliation, Error DisclosureNever Events, and Rapid Response Systems. (Accessed January 2014)

  • Patient Safety Toolkits. Seventeen toolkits are available to help make health care safer for patients. These toolkits have solutions for addressing the challenges that occur in hospitals and outpatient facilities during handoffs and discharges, in day-to-day work processes, while reconciling medications, and more. Toolkits are listed by setting and user, by patient safety issue/area, and by Joint Commission National Patient Safety Goal.

American Academy of Pediatrics

  • 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. (Accessed June 2010)

  • 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. (June-July 2005)

Duke University Medical Center Library

  • 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. (December 2009)

Illinois EMSC

  • The Illinois EMSC program has made patient safety a priority with Patient Safety in Pediatric Emergency Care.  This extensive educational resource, designed for all providers of pediatric emergency are, contains two sections.  Part one focuses on background information and statistics to help health care professionals understand the severity of patient safety issues while part two addresses the 2004 Joint Commission National Patient Safety Goals (2004).

National Patient Safety Foundation

  • Unmet Needs: Teaching Physicians to Provide Safe Patient Care.  Concerned that U.S. medical schools may not always facilitate development of skills required for the provision of safe patient care, the National Patient Safety Foundation uses this report to make key recommendations for reforming medical education in order to improve patient safety. (2010)

The Joint Commission

  • Facts about Patient Safety. With its mission of improving healthcare by evaluating healthcare organizations on specific performance standards, the Joint Commission accredits and certifies more than 17,000 health organizations and programs in the U.S. Further, the Joint Commission and the American Academy of Pediatrics have published Pediatric Patient Safety in the Emergency Department, a self-described road map to assure safe care for children in hospital emergency departments. (2010)

Washington Patient Safety Coalition 

  • 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, etc.) to help promote the initiative's goal among target audiences. (Accessed January 2014)

  • Patient Safety Web Sites and Resources.  This section of the Washington Patient Safety Coalition’s website provides a range of websites and links to tools considered pertinent to those involved with improving safety and reducing error.  Topics addressed include medication safety, error disclosure, laboratory safety and quality, procedure safety, and patient safety culture. (Accessed January 2014)



EXAMPLE PRACTICES/MODEL PROGRAMS

  • Illinois EMSC. The Illinois EMSC Program uses a Continuous Quality Improvement (CQI) approach to improve the quality (and corresponding safety) of care within the state’s pediatric emergency and critical care system.  The program has assisted in the development of pediatric quality improvement committees within each of the eleven EMS regions to enhance prehospital and emergency department quality improvement activities. Each regional CQI committee identifies quality indicators of local interest and defines a related record review tool.  The CQI committee members then perform reviews of cases at their own facility for comparison to their peer facilities.  From 2001 through 2005, more than 30,000 records have been reviewed for quality in this EMSC CQI process by more than 100 hospital emergency departments.  (Accessed January 2014)

  • The Josie King Patient Safety Program at Johns Hopkins Childrens Center. Following the preventable death of a pediatric patient, the Josie King Patient Safety Program at Johns Hopkins Children’s Center was established to improve pediatric patient safety.  The program began with a quality improvement initiative driven by data and documentation.  The Pediatric Intensive Care Unit (PICU) and Children’s Medical Surgical Center staff participated in a survey gauging the hospital’s safety culture, identifying areas where problems might arise and how the institution could best prevent them.  Senior management was involved to encourage staff to freely raise concerns, provide rapid and meaningful feedback, and develop trust.  Based on staff recommendations for resource allocation and problem management, the Patient Safety Program provided the PICU, surgical center, senior management, and various departments with means to increase accountability in order to prevent harm.  Both patients and staff were able to see and understand subtle changes that created significant improvements in their well-being.  (Accessed January 2014)

  • University of Pittsburgh Medical Center Shadyside's Condition H. UPMC Shadyside's Condition H model was created to address the needs of the patient and family in case of an emergency or when the patient is unable to get the attention of a healthcare provider in an emergency situation.  At the time of hospital admission, patients are provided a telephone number to dial if they feel they are not receiving adequate medical attention or if they become concerned over what is happening.  The trained hospital operator receives the call, announces the condition, and enters information into the responding teams’ pagers. Within minutes, a rapid response team of healthcare professionals arrives to the patient bedside to remedy the problem. Information is collected on a survey questionnaire after the situation is stabilized. Within 24 hours of the Condition H call, a team member revisits the caller to ensure the patients needs have been met. Follow up calls are also made to patients once they are discharged from the hospital to learn more about patient satisfaction with the program. This process allows UPMC Shadyside to learn where areas of program opportunity exist, and serves as model patient safety initiative involving both patients and their families. (Accessed January 2014)



FAMILY AND CAREGIVER RESOURCES

University of Virginia Health System

Washington Patient Safety Coalition

  • My Medicine List. 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 healthcare 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. (June 2010)

FamilyDoctor.org

  • Medical Errors: Tips to Help Prevent Them. This web resource from FamilyDoctor.org empowers patients to take an active role in reducing the potential for healthcare errors by communicating with their healthcare team, asking appropriate questions, learning more about recommended treatments, and taking responsibility for their healthcare. (December 2009)