Patient Safety Tip of the Week
January 31, 2017 More Issues in
Pediatric Safety
In our January 17,
2017 Patient Safety Tip of the Week “Pediatric
MRI Safety” we noted that
many safety issues for children undergoing MRI result from the confluence of
vulnerable patients being temporarily in an environment where communication and
coordination issues can be problematic. But communication issues can affect the
safety of pediatric patients in almost any venue. Young children obviously must
rely on parents, other adults, and other caregivers for overseeing their
safety. Moreover, they may be unable to convey their own feelings or symptoms,
at least in a verbal fashion. Children are also vulnerable to errors because
doses of their medications and IV fluids may require calculations based upon
weight and such calculations may be subject to errors.
But the behavior of
parents can also affect the care their children receive. In our September 22, 2015 Patient Safety Tip of the
Week “The
Cost of Being Rude” we discussed a study (Riskin
2015) showing shown how
rudeness among the healthcare team can negatively impact performance. Now the
same researchers have demonstrated in simulation exercises that rudeness by
parents may also negatively impact performance by healthcare workers (Riskin
2017).
They randomly assigned
NICU teams to either an exposure to rudeness (in which the comments of the
patient’s mother included rude statements completely unrelated to the teams’
performance) or control (neutral comments) condition. Rudeness had adverse
consequences not only on diagnostic and intervention parameters but also on
team processes, such as information and workload sharing, helping and
communication, central to patient care.
There’s little question that even such subtle
behaviors can introduce biases that may foster diagnostic errors. There has
recently also been attention in the adult patient safety literature to the
occurrence of diagnostic errors in patients who exhibit disruptive behaviors (Mamede 2017, Redelmeier
2017).
Communication issues were also a key finding in a recent analysis of primary care patient
safety incidents involving sick children from England and Wales’ National
Reporting and Learning System between 2005 and 2013 (Rees
2017). Of the 2,191 safety
incidents, 30% were harmful, including 12 deaths and 41 cases of severe harm.
The researchers identified several priority areas for improvement:
- safer systems for medication provision in community pharmacies
- triage processes to enable effective and timely assessment,
diagnosis and referral of acutely sick children attending out-of-hours
services
- enhanced communication for robust safety netting between
professionals and parents
We don’t know enough
about the UK telephone triage system(s) to know whether such systems in
the US may be vulnerable to the same issues. In such systems, the person
receiving the phone call from a parent concerned about their child lets the
parent describe the problem, then selects a computerized protocol that prompts
them to ask further questions, after which they provide advice. In the Rees
study two common issues were: (1) choosing the wrong protocol (for example,
choosing the “head wound” rather than the “head trauma” protocol) and (2) failure
to use “critical thinking”. We wonder if some of the latter was really a matter
of the telephone advisors simply not having adequate training in some areas.
For example, one incident described a feverish 4-month old who had asymmetric
pupils and a hard fontanelle. The health advisor commented that he did not know
the implications of a hard fontanelle and followed a simple “generally unwell”
protocol and incorrectly answered that the infant was able to respond normally
despite the mother’s comment that the infant was “dazed” and “drowsy, not with
it”.
As you might expect,
medication-related incidents were most common and over half were related
to dispensing errors in community pharmacies. Anticonvulsants, antibiotics, and
asthma medications were implicated most often. Wrong dosage, wrong medication,
and incorrect labeling were specifically mentioned. Communication errors with
the parent contributed frequently to medication errors, especially when the
parents were administering the medication at home.
We’ve previously
described how parental health literacy, numeracy in particular,
can render children vulnerable to medication errors (see our What’s New in the Patient Safety World
columns for June 2012 “Parents'
Math Ability Matters” and November 2014 “Out-of-Hospital
Pediatric Medication Errors” and our January 13, 2015 Patient Safety Tip of
the Week “More
on Numeracy”).
Dosing errors related to the vehicles used for administration
of medications to children have
also been problematic. In our What's New in the Patient Safety World columns
for April 2015 “Pediatric
Dosing Unit Recommendations” and September 2015 “Alert:
Use Only Medication Dosing Cups with mL Measurements” we discussed use of
metric units for liquid medications administered to pediatric patients (AAP
2015). Use of measures such as
“teaspoon” and “tablespoon” should no longer be used. Moreover, the correct
abbreviation for milliliters is “mL” (rather than “ml”, “ML”, or “cc”).
Dispensing devices are also critical. Pharmacies, hospitals, and healthcare
centers should distribute appropriate-volume milliliter-based dosing devices
such as syringes. And the syringe (or other dosing device) should not be
significantly larger than the dose prescribed. And a national alert
recommended hospitals replace medication dosage cups that use units other than
mL (NAN 2015).
The 2015 AAP
statement also recommends that manufacturers avoid labeling, instructions or
dosing devices that contain units other than metric units. But poorly designed
labels and packaging continue to contribute to errors. A recent study in 3
urban pediatric clinics (Yin
2016) randomly assigned parents to 1 of 5 study arms and given labels and
dosing tools that varied in unit pairings. 84.4% of parents made 1 or more dosing
errors and 21.0% made 1 or more large error. More errors were seen with cups
than syringes, especially for smaller doses. Use of a teaspoon-only label (with
a milliliter and teaspoon tool) was associated with more errors than when
milliliter-only labels and tools were used. The authors recommend that use of oral
syringes over cups, particularly for smaller doses, should be part of a
comprehensive pediatric labeling and dosing strategy to reduce medication
errors.
Children are also more vulnerable to 10-fold dosing errors,
primarily because dose calculations often result in results with decimal
points. The decimal points can be overlooked, resulting in administration of a
dose that is 10 times (or 100 times if there are two digits following the decimal
point) higher than intended. In our September 2011 “Dose
Rounding in Pediatrics” we discussed under which circumstances it might be
appropriate to keep a decimal point and when the dose should simply be rounded
to eliminate the need for a decimal point.
More information on pediatric medication errors outside the
hospital can be found in our November
2014 What's New in the Patient Safety World column “Out-of-Hospital
Pediatric Medication Errors” and May 7, 2013 Patient Safety Tip of
the Week “Drug
Errors in the Home”.
We’ve also discussed the problems often seen with opioids in children, particularly those
related to use of codeine (see columns listed below). These columns described the
original cases of death and serious adverse effects in children treated with
codeine following adenotonsillectomy for obstructive sleep apnea. The problem
originally noted for codeine was that there are genetic variations that cause
some people to be “ultra-rapid metabolizers” of codeine, which leads to higher
concentrations of morphine in the blood earlier. But recommendations have now
gone further than just avoiding codeine after adenotonsillectomy and it is now
recommended that codeine not be used for pain or cough in children. And
children are often the victims of accidental ingestion of discarded transdermal
patches of fentanyl or other dangerous medications.
Our March 15, 2016
Patient Safety Tip of the Week “Dental
Patient Safety” had an
extensive section on the adverse outcomes of pediatric patients receiving
sedation. Young children are particularly vulnerable because they are often
sedated since they may be uncooperative for dental procedures. Moreover, many
such incidents have occurred when a child is restrained by a device
called a “papoose”. Proper procedures
and guidelines for pediatric sedation were discussed in our August 2016 What's
New in the Patient Safety World column “Guideline
Update for Pediatric Sedation”.
Overdiagnosis, overutilization of testing, and overtreatment may result in harm to
children, just as it can in adults. We’ve often discussed the Imaging
Gently® and Imaging Wisely®
campaigns, which are attempts to reduce the inappropriate use of imaging with
ionizing radiation when safer alternatives are available (see, for example, our
January 2017 What's New in the Patient Safety World column “Still
Too Many CT Scans for Pediatric Appendicitis”). A recent review of articles published in just one year (2015)
provides insight into the magnitude of these problems in children (Coon
2017). Their findings included evidence for overdiagnosis of hypoxemia in
children with bronchiolitis and skull fractures in children suffering minor
head injuries. Findings of overtreatment included evidence that up to 85% of
hospitalized children with radiographic pneumonia may not have a bacterial
etiology; many children are receiving prolonged intravenous antibiotic therapy
for osteomyelitis although oral therapy is equally effective; antidepressant
medication for adolescents and nebulized hypertonic saline for bronchiolitis
appear to be ineffective; and thresholds for treatment of hyperbilirubinemia
may be too low. Regarding overutilization, they suggested that the frequency of
head circumference screening could be relaxed; large reductions in abdominal
computed tomography testing for appendicitis appear to have been safe and effective;
and overreliance on C-reactive protein levels in neonatal early onset sepsis appears
to extend hospital length-of-stay.
Pediatric safety issues such as car and bicycle safety, accidental
poison ingestions, falls, firearm accidents, and others are beyond the scope of
today’s column.
These are but a few of the many possible patient safety
issues potentially affecting one of our most vulnerable patient populations.
Some are due to the unique biological and physiological characteristics of
children but even more may be related to the fact that communication, which is
always an error-prone process, usually happens through third parties rather
than directly with children.
Some of our other
columns on pediatric medication errors:
November 2007 “1000-fold
Overdoses by Transposing mg for micrograms”
December 2007 “1000-fold
Heparin Overdoses Back in the News Again”
September 9, 2008 “Less
is More and Do You Really Need that Decimal?”
July 2009 “NPSA
Review of Patient Safety for Children and Young People”
June 28, 2011 “Long-Acting
and Extended-Release Opioid Dangers”
September 13, 2011 “Do
You Use Fentanyl Transdermal Patches Safely?”
September 2011 “Dose
Rounding in Pediatrics”
April 17, 2012 “10x
Dose Errors in Pediatrics”
May 2012 “Another
Fentanyl Patch Warning from FDA”
June 2012 “Parents’
Math Ability Matters”
September 2012 “FDA
Warning on Codeine Use in Children Following Tonsillectomy”
May 7, 2013 “Drug
Errors in the Home”
May 2014 “Pediatric
Codeine Prescriptions in the ER”
November 2014 “Out-of-Hospital
Pediatric Medication Errors”
January 13, 2015 “More
on Numeracy”
April 2015 “Pediatric
Dosing Unit Recommendations”
September 2015 “Alert:
Use Only Medication Dosing Cups with mL Measurements”
November 2015 “FDA
Safety Communication on Tramadol in Children”
Some of our previous
columns on opioid safety issues in children:
- September 2012 “FDA
Warning on Codeine Use in Children Following Tonsillectomy”
- March 2013 “Further
Warning on Codeine in Children Following Tonsillectomy”
- May 2014 “Pediatric
Codeine Prescriptions in the ER”
- November 2015 “FDA
Safety Communication on Tramadol in Children”
- January 2016 “FDA
Gets Even Tougher on Codeine in Kids”
- October 2016 “Another
Codeine Warning for Children”
References:
Riskin A, Erez A, Foulk TA, et al. The Impact of Rudeness on
Medical Team Performance: A Randomized Trial. Pediatrics 2015; 136: 487-495
http://pediatrics.aappublications.org/content/136/3/487.abstract
Riskin A, Erez A, Foulk TA, et al. Rudeness and medical team
performance. Pediatrics 2017;
doi:10.1542/peds.2016-2305
Mamede
S, Van Gog T, Schui SCE, et al. Why patients’ disruptive behaviours impair
diagnostic reasoning: a randomised experiment. BMJ Qual Saf 2017; 26: 13-18
http://qualitysafety.bmj.com/content/26/1/13.full
Redelmeier
DA, Etchells EE. Unwanted patients and unwanted diagnostic errors. BMJ Qual Saf
2017; 26: 1-3
http://qualitysafety.bmj.com/content/26/1/1.full.pdf+html
Rees P, Edwards A, Powell C, et al. Patient Safety Incidents
Involving Sick Children in Primary Care in England and Wales: A Mixed Methods
Analysis. PLOS One Medicine 2017; published January 17, 2017
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002217
AAP (American Academy of Pediatrics). Committee on Drugs.
Policy Statement. Metric Units and the Preferred Dosing of Orally Administered
Liquid Medications. Pediatrics 2015; 135(4): 784-787; originally published
online March 30, 2015
http://pediatrics.aappublications.org/content/early/2015/03/25/peds.2015-0072.full.pdf
NAN (National Alert Network). Move toward full use of metric
dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups
that measure mL. NAN 2015; June 30, 2015
http://www.ismp.org/NAN/files/NAN-20150630.pdf
Yin HS, Parker RM, Sanders LM, et al. Liquid Medication
Errors and Dosing Tools: A Randomized Controlled Experiment. Pediatrics 2016;
published online early September 12, 2016
http://pediatrics.aappublications.org/content/early/2016/09/08/peds.2016-0357
Imaging Gently®
Imaging Wisely®
Coon
ER, Young PC, Quinonez RA, et al. Update on Pediatric Overuse. Pediatrics 2017;
Published Ahead of Print January 3, 2017
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