In our September 2012 Whats New in the Patient Safety World column Canadian Paediatric Adverse Events Study we discussed a study using a trigger tool to assess rates of adverse events in hospitalized pediatric patients in Canada (Matlow 2012). The overall rate of adverse events was 9.2%. The overall rate of adverse events was almost 3 times higher in the academic centers but this was largely driven by a higher rate of non-preventable adverse events.
A new study (Ahuja 2012) shows that the medical error rate in pediatric inpatients in the US is proportionate to the number of chronic conditions that the child has. Those researchers used the large KID (2006 Kids Inpatient Database) database and ICD-9-CM codes for iatrogenic medical errors. While the overall rate of medical errors was 3.0 per 100 discharges, there was a big disparity between rates for children with and without chronic conditions. For those without chronic conditions the rate was 1.3 per 100 discharges whereas for those with one or more chronic conditions it was 5.3 per 100 discharges. Moreover, the rates increased in proportion to the number of chronic conditions, though in the adjusted models this tended to level off somewhat once 3 chronic conditions were reached.
They also noted that the error rates were higher in urban hospitals, teaching hospitals, childrens hospitals, and general hospitals with childrens units. These hospitals also had higher numbers of patients with chronic conditions.
So how does this study mesh with the Canadian Paediatric Adverse Events Study? The adverse event rates were higher in the Canadian study. However, that largely reflects different methodologies and not measuring exactly the same things. The Canadian study utilized a trigger tool methodology, which has been shown to uncover many more events than seen in studies using administrative databases only. The use of ICD-9_CM coding for errors in the Ahuja study would be expected to pick up considerably fewer adverse events. So that latter study certainly does not imply that medical error rates are any lower in the US than in Canada.
But both studies add considerably to our knowledge base. The Canadian study also showed higher overall adverse event rates in teaching hospitals (though the higher rates were primarily in the nonpreventable category) and this may well be due to the higher percentage of patients with chronic illnesses at those hospitals as well. It certainly makes sense that patients who are sicker and on more complex medication regimens and interact with the healthcare system more often are probably going to be the most vulnerable to medical errors. We certainly see that in the adult population as well.
References:
Matlow AG, Baker GR,
Flintoft V, et al. Adverse events among children in Canadian hospitals: the
Canadian Paediatric Adverse Events Study. CMAJ 2012; July 30, 2012 First
published July 30, 2012, doi: 10.1503/cmaj.112153
July 30, 2012
http://www.cmaj.ca/content/early/2012/07/30/cmaj.112153
Ahuja N, Zhao W, Xiang
H. Medical Errors in US Pediatric Inpatients With Chronic Conditions. Pediatrics 2012; 130: e786-e793 Published
online September 10, 2012
http://pediatrics.aappublications.org/content/early/2012/09/04/peds.2011-2555.full.pdf+html
Print October
2012 More on Medical Errors in Children
In our January 25,
2011 Patient Safety Tip of the Week Procedural
Sedation in Children we mentioned the Pediatric Sedation Research
Consortium (PSRC). Thats a large collaborative group of institutions doing
sedation for procedures in pediatrics who have come together to share data and
foster research. They now have accumulated data on over 100,000 children
undergoing sedation for procedures outside the operating room (including
procedures such as MRI scans, lumbar punctures, bone marrow biopsies,
endoscopies, etc.).
While the overall
rates of serious adverse events have been relatively low, a new study from the
PSRC (Langhan
2012) shows wide variation in compliance with monitoring guidelines during
procedural sedation. Guidelines published by the American Academy of
Pediatrics, American College of Emergency Physicians, and American Society of
Anesthesiologists were adhered to in only 52% of procedures.
They noted
tremendous variability between specialties in the monitoring used. Of
particular concern, radiologists used pulse oximetry in only a third of cases
and did not use any monitoring in about 40% of cases.
Weve done numerous
articles (see the list at the end of this article) on radiology as a high risk
area for a variety of reasons, many of which are not directly related to
radiology. But procedural sedation is one of the areas directly related to
radiology personnel. Whats compliance with monitoring like in your radiology
department?
We hope youll look
at our extensive discussion on procedural sedation in our January 25, 2011
Patient Safety Tip of the Week Procedural
Sedation in Children.
Some of our prior columns on procedural sedation:
·
May 25, 2010 Propofol
Issues
·
August 2012 Sedation
Costs for Pediatric MRI
· January 25, 2011 Procedural Sedation in Children
· May 2011 Update on Pediatric Procedural Sedation
· August 2011 NEJM Video on Conscious Sedation for Minor Procedures in Adults
· October 2011 The Procedural Sedation Debate Rages On
· April 2012 Problems with Ketofol
Some of our prior columns on patient safety issues in the radiology suite:
· October 16, 2007 Radiology as a Site at High-Risk for Medication Errors
· September 16, 2008 More on Radiology as a High Risk Area
·
October 7, 2008 Lessons
from Falls....from Rehab Medicine
·
January 2010 Falls
in the Radiology Suite
·
August 2010 Sedation
Costs for Pediatric MRI
·
January 25,
2011 Procedural
Sedation in Children
·
February 19, 2008 MRI
Safety
References:
Langhan ML, Mallory
M, Hertzog J, Lowrie L, Cravero J for the Pediatric Sedation Research
Consortium. Physiologic Monitoring Practices During Pediatric Procedural
Sedation. A Report From the Pediatric Sedation Research Consortium. Arch Pediatr Adolesc Med 2012; Published online September 10, 2012
http://archpedi.jamanetwork.com/article.aspx?articleid=1357757
Print October
2012 Monitoring During Procedural Sedation in Children
Over 20 years ago a
group of hospitals in the WNY region collaborated with a local payer to see if
we could predict outcomes in hospitalized patients based on readily available
parameters such as lab test results (unpublished data). At the top of our list
was serum sodium. Hyponatremia was a very good predictor of adverse outcomes in
the hospitalized adult population. Subsequent published studies have
demonstrated hyponatremia is a good predictor of mortality, length of stay and
overall costs.
Now a new study (Leung
2012) shows that preoperative hyponatremia in patients undergoing surgery
predicts higher 30-day mortality and more numerous complications, including
wound infections, perioperative cardiovascular events, and pneumonia. After
adjustment for confounding factors, length of stay in patients with
preoperative hyponatremia is also about a day longer.
Perhaps the most
interesting finding was that the risks were increased the most in patients
undergoing nonemergent surgery and those in the lowest ASA classes, hence
patients who would ordinarily be considered less risky.
The debate is around
whether the hyponatremia is simply a marker of higher risk or is somehow
causally related to the adverse outcomes. Most likely it is simply a marker of
higher risk. Hyponatremia is commonly seen in patients with multiple
comorbidities (including conditions like heart failure, chronic liver or kidney
disease, cancer, etc.) and patients on multiple medications.
Of course, what is
not known is whether correction of the hyponatremia preoperatively reduces
these excess risks. That would require a randomized controlled trial of
considerable magnitude and complexity (since the etiology and management of
hyponatremia is quite diverse).
As weve pointed out on numerous occasions, screening for risk factors may be important from a prognostic standpoint but really adds little other than cost if you dont have interventions that are shown to reduce that excess risk.
References:
Leung AA, McAlister
FA, Rogers SO, et al. Preoperative Hyponatremia and Perioperative Complications.
Arch Intern Med 2012; Published
online September 10, 2012
http://archinte.jamanetwork.com/article.aspx?articleid=1357514
Print October
2012 Hyponatremia Predicts Surgical Complications
ISMP Canada this month has a good article about another look-alike/sound-alike (LASA) drug mixup, this time between bisoprolol and bisacodyl (ISMP Canada 2012). The former drug is a beta blocker and the latter a stimulant laxative so mixups between these two drugs can have potentially significant consequences for patients. They analyzed not only the index case reports but found 32 such mixups involving this drug pair in their database. The article is worth reading not just from the standpoint of this specific LASA pair but provides good information on how LASA errors are enabled at each stage of the medication process.
They cover such issues as the need to spell out the drug name rather than just repeating the name when receiving a verbal order, handwriting legibility errors, lack of including indication for use, choosing adjacent drugs from drop-down lists, using drug mnemonic codes that are confusing, failure to recognize unusual dosages, failure to recognize that prn use of the beta-blocker would be inappropriate, storage of such medications in proximity (particularly if purchased from the same vendor there may be further similarities in packaging and labeling), and failure to involve the patient or caregiver in the medication administration process.
They have a good discussion on how confirmation bias increases the likelihood of many LASA errors.
Read the article and then make sure your systems incorporate the suggested interventions to prevent such mixups in your facilities, not just for this particular LASA pair but for LASA pair mixups in general.
References:
ISMP Canada. Concerned Reporting: Mix-ups Between Bisoprolol and Bisacodyl. ISMP Canada Safety Bulletin 2012; 12(9): 1-6 August 30, 2012
Print October
2012 ISMP Canada: Another Look-Alike/Sound-Alike Issue
In our February 21,
2012 Patient Safety Tip of the Week Improving
PCA Safety with Capnography we mentioned that the Physician-Patient
Alliance for Health & Safety (PPAHS) had a
workgroup addressing PCA safety. On their website are some
heart-wrenching stories about patients who died during PCA, likely as a result
of inadequate monitoring. We said we look forward to seeing that checklist when
it is ready. Well, the PPAHS has now released
that checklist for PCA pump safety (PPAHS
2012). Their website not only has the link to the PCA
Safety Checklist itself but also links to several columns and blogs
regarding PCA safety, PCA hazards, monitoring, capnography, etc. These are
excellent resources.
Another excellent resource on PCA safety is the San Diego
Patient Safety Council and the San
Diego Patient Safety Taskforce, which put together a tool
kit for PCA safety. It is a comprehensive document that discusses
assessment for PCA appropriateness, distinction between opioid naοve and opioid
tolerant patients, PCA patient education, pain assessment, sedation assessment,
respiratory assessment, monitoring, adjuvant therapies (eg. for treating side
effects of opioid therapy such as constipation, nausea and vomiting, pruritis),
multimodal pain management strategies, standardized order sets, and specific
issues related to equipment and products.
In our May 17, 2011 Patient Safety Tip of the Week Opioid-Induced Respiratory Depression Again! we encouraged hospitals to perform their own FMEA (Failure Mode and Effects Analysis) on the PCA process and provided links to two tools we use when doing FMEAs of the PCA pump process: the PCA Pump Audit Tool and the PCA Pump Criteria. And we hope that youll go back and look at the string of recommendations we made in our September 6, 2011 Patient Safety Tip of the Week More Tips on PCA Safety. We think you will find them extremely helpful. And dont forget that most of the issues pertaining to patients on PCA pumps apply also to patients receiving postoperative opioids by other routes.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
References:
PPAHS (Physician-Patient
Alliance for Health & Safety)
PPAHS (Physician-Patient
Alliance for Health & Safety). Physician-Patient Alliance for Health &
Safety Announces New Expert Checklist for Facilitating Safety of Hospital-Based
Intravenous Patient-Controlled Analgesia Pumps. July 17, 2012
PPAHS. PCA Safety
Checklist.
http://ppahs.files.wordpress.com/2012/07/pca-safety-checklist3.pdf
San Diego Patient
Safety Taskforce. Tool Kit: Patient Controlled Analgesia (PCA) Guidelines of
Care for the Opioid Naοve Patient. Published: December 2008
http://www.patientsafetycouncil.org/uploads/Tool-Kit-PCA_Dec_2008.pdf
Print October
2012 Another PCA Pump Safety Checklist
Print October
2012 What's New in the Patient Safety World (full column)
Print October
2012 More on Medical Errors in Children
Print October
2012 Monitoring During Procedural Sedation in Children
Print October
2012 Hyponatremia Predicts Surgical Complications
Print October
2012 ISMP Canada: Another Look-Alike/Sound-Alike Issue
Print October
2012 Another PCA Pump Safety Checklist
http://www.patientsafetysolutions.com/