The pediatric literature this past month has had an intense focus on patient safety for children. The American Academy of Pediatrics issued a Policy Statement Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care (Mueller 2019). And a consortium of Childrens Hospitals compiled a prioritized list of research topics for pediatric patient safety (Hoffman 2019).
The AAP policy statement (Mueller 2019) begins with an excellent review of the literature on pediatric patient safety issues. It then goes into the safety culture, which includes human factors concepts, and discusses the concepts of human fallibility, organizational culture, reporting culture, learning culture, flexible culture, and just culture. It goes on to discuss many of the strategies and approaches to patient safety and the roles of leadership, healthcare information technology, and goals set not only by The Joint Commission but also by a variety of other professional organizations. The appendices and reference list provide excellent links to useful information and tools.
It ends with a set of recommendations:
1. Raise awareness and improve working knowledge of pediatric patient safety issues and best practices throughout the pediatric community.
· Educate and train
· Create a safety culture
· Implement and use standardized protocols of care for specific conditions, such as checklists or clinical practice guidelines, and monitor adherence
· Expand focus (for example, to safety in ambulatory settings and other locations where children receive care, including the home and school environments)
2. Act and advocate to minimize preventable pediatric medical harm by using information on pediatric-specific patient-safety risks.
· Develop pediatric-specific error reporting
· Identify trends and areas in need of action
· Foster leadership
· Enhance family-centered care, actively engage patients and families in safety at all points of care, and address issues of ethnic culture, language, and health literacy.
3. Improve health care outcomes for children by adhering to proven best practices for improving pediatric patient safety.
· Adhere to best practices
· Target drug safety
· Help redesign clinical systems
· Leadership to support and expand research (locally, regionally, and nationally)
See the AAP paper for details on each of these recommendations.
The second paper comes from the Childrens Hospitals Solutions for Patient Safety Network, a network of >100 childrens hospitals working together to eliminate harm due to health care. They engaged key stakeholders (importantly, including parents) in an iterative process to identify and prioritize topics on pediatric patient safety (Hoffman 2019). They developed a final list of 24 topics. Top-priority research topics concerned high reliability, safety culture, open communication, and early detection of patient deterioration and sepsis. Further discussion with health system executives put the following at the top of their list as priority areas: diagnostic error, medication safety, deterioration, and ambulatory patient safety.
For years, our pediatric colleagues have been reminding us that kids are not just little adults. And that does ring true when it comes to patient safety. There are clearly vulnerabilities in infants and children that render them at risk for a variety of patient safety hazards. So we went back and reviewed our own patient safety columns related to children over the years, and we clearly see the impact of those vulnerabilities. We noted several key contributing factors:
· Body size, weight, surface area differences
· Communication limitations
· Cognitive skills not fully developed
· Genetic vulnerabilities (eg. rapid metabolizers)
· Someone else makes decisions for them (eg. numeracy of parents)
· Confusion about devices used to administer medications
· Immune systems immature
· Difficulty holding still (dental or other sedation)
· Kids play and are inquisitive (eg. may put discarded opioid patches in their mouths)
· Longer time for exposure to radiation effects
· Not included in clinical trials
· Similarities of names in neonatal units
Medication safety would have been at the top of our list and many of the vulnerabilities unique to children lead to adverse medication events. Compared to adults, where standardized doses are typically used, children have different body weights and surface areas that lead to the need to calculate their medication doses. Any time you have to perform a calculation, youve added an additional threat layer (see our many columns on dosing errors and dose rounding issues). Moreover, someone else is usually making medical decisions or management and they may be prone to error (see our columns on parental numeracy issues). Genetically-determined vulnerabilities are often first brought to light in children (for example, the rapid metabolizer issue that renders children at risk from use of codeine). The fact that children are often excluded from clinical trials may preclude them from benefiting from certain drugs but may also put them in harms way when someone uses those drugs in a population where they have not been adequately assessed for safety and efficacy.
Because they may not be able to communicate with us, they cannot tell us hey, youve got the wrong patient!. They may not be able to communicate to us that they are having an adverse reaction to a medication weve given them. And inability to communicate may impede our ability to recognize early clinical deterioration in patients with sepsis or other conditions.
Infants and children cant be expected to hold still for diagnostic studies like CT or MRI or for therapeutic interventions like dental work. Therefore, they are given sedation for such events and are put at risk for the unwanted consequences of sedation (respiratory depression, aspiration, etc.).
Kids are inquisitive and like to play. That puts them at risk for finding things like discarded opioid transdermal patches, which can lead to disaster if they put these in their mouths or attach them to their skin. They can get into medicine cabinets (or other places where medications intended for their parents or siblings are kept) and ingest medications that will harm them. Weve also noted cases where kids had ingested magnets and underwent MRI with consequent burning of GI tissues.
Most of our columns on the effects of unnecessary radiation exposure have focused on children. The carcinogenic risks from ionizing radiation often depend upon cumulative doses and children obviously have a much longer lifespan that allows for more total radiation exposure.
While we listed similarity of names in neonatal units, there are actually many factors that contribute to misidentification issues in newborns. Our numerous columns on this topic are listed below.
And weve not even touched upon the many other safety hazards for children that are not directly related to medical care but should be addressed by healthcare professionals when they interact with infants and children and their families. These include topics like gun safety, bicycle and automobile (or other vehicles) safety, sports safety, drugs, smoking, bullying, and other topics. We pointed to some good references for those topics in our January 2019 What's New in the Patient Safety World column Pediatric Health and Safety Guide.
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
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
October 2016 Another Codeine Warning for Children
January 31, 2017 More Issues in Pediatric Safety
August 2017 Medication Errors Outside of Healthcare Facilities
August 2017 More on Pediatric Dosing Errors
September 2017 Weight-Based Dosing in Children
Some of our previous columns on opioid safety issues in children:
Some of our previous columns on sedation issues in children:
· March 15, 2016 Dental Patient Safety
· March 28, 2017 More Issues with Dental Sedation/Anesthesia
· November 28, 2017 More on Dental Sedation/Anesthesia Safety
Some of our prior columns related to identification issues in newborns:
· November 17, 2009 Switched Babies
· December 20, 2011 Infant Abduction
· September 4, 2012 More Infant Abductions
· December 11, 2012 Breastfeeding Mixup Again
· April 8, 2014 FMEA to Avoid Breastmilk Mixups
· August 2015 Newborn Name Confusion
· January 19, 2016 Patient Identification in the Spotlight
· July 19, 2016 Infants and Wrong Site Surgery
· August 1, 2017 Progress on Wrong Patient Orders
Some of our prior columns related to radiation issues in children:
· November 23, 2010 Focus on Cumulative Radiation Exposure
· January 2017 Still Too Many CT Scans for Pediatric Appendicitis
Miscellaneous columns on other pediatric patient safety topics:
· January 2019 Pediatric Health and Safety Guide
Mueller BU, Neuspiel DR, Stucky ER, Fisher S, Council on Quality Improvement and Patient Safety. American Academy of Pediatrics. Policy Statement.
Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics 2019; 143(2): e20183649 February 2019
Hoffman JM, Keeling NJ, Forrest CB, et al. Priorities for Pediatric Patient Safety Research. Pediatrics 2019; Jan 2019: e20180496 January 23, 2019
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