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A new tool for tracking harm in hospitalized children

In the 15 years since the Institute of Medicine issued its groundbreaking report showing frequent harm caused by medical care, researchers have worked to devise efficient, reliable ways to detect harm to patients. Finding out what aspects of care most often hurt patients is a key step in reducing these harms, but voluntary reports, in which caregivers are asked to document harm they cause, only identify a small percentage of total harms.

New research published today in Pediatrics describes a better approach for tracking harm to kids in hospitals. Using the system on 600 medical charts from six U.S. children's hospitals, the researchers found that almost 25 percent of patients included in the chart review had experienced at least one harm, and that 45 percent of these harms were probably preventable. The approach, called a "trigger tool," was based on a similar harm-tracking method designed for hospitalized adult patients. Researchers look at each medical chart for "triggers" - events or lab measurements often associated with harm - and when they find a trigger, explore the medical chart in detail around the time of the trigger to see if harm occurred.

"This tool will allow us to better understand the epidemiology of harm in hospitalized children, as well as give us the capacity to track harms over time to determine if our interventions are making an improvement," said senior study author Paul Sharek, MD, an associate professor of pediatrics and chief clinical patient safety officer at Lucile Packard Children's Hospital Stanford and Stanford Children's Health. He collaborated with scientists from several other institutions on the research.

I talked with Sharek last week about the study's findings and implications. To start, I asked him to give me an example that would help me understand the difference between preventable and non-preventable harm. A child who receives a medication that provokes an allergic reaction has experienced a non-preventable harm if it's the first time the child ever got the drug, and there were no clues beforehand that she had the allergy, he told me. But if the drug allergy was already known and the patient got the drug anyway and had an allergic reaction, that is a preventable harm.

The high rate of preventable harms shows that there is a lot of room to make all hospitals safer for kids, Sharek said. One surprise in the data was that nine common healthcare-acquired conditions that have been targeted by national safety efforts - including central line-associated bloodstream infections, ventilator-associated pneumonia and surgical site infections - together accounted for only 4 percent of all harms identified in this study. "If we were able to eliminate every one of these, according to these data, we'd still be left with 96 percent of the harms we identified," Sharek said.

According to the new study, the most common cause of harm to pediatric hospital patients was infiltration and complications of intravenous lines, both central and peripheral. "This gives us a clue as to our next safety focus in pediatrics," Sharek said. "We should focus more aggressively on the use and care of IV lines and on being more aggressive in our attempts to remove them quickly." The Solutions for Patient Safety Collaborative, a collection of 88 children's hospitals across the U.S. and Canada, is adding peripheral IV infiltration to the other harms it is targeting, in part as a result of the study findings, he noted.

Another important element of the new trigger tool is that was designed to eventually integrate into electronic medical records. Though this hasn't happened yet, Sharek envisions a day when electronic medical records will help doctors and nurses see triggers in real time. "Many of the triggers are harm precursors that can be detected before the full harm has occurred," he said. For instance, a rising creatinine level can be an early warning sign of problems with kidney function. An electronic medical record could give alerts to caregivers that would prompt them to investigate why the patient's creatinine was increasing. "That would give us the ability to mitigate harm, or even prevent it from happening altogether," Sharek said. "The ability to predict harm before it occurs, and then act to prevent it, is the ultimate goal of patient safety efforts. This pediatric global trigger tool, when integrated into the electronic medical record, will allow us to do just that."

Previously: Less burnout, better safety culture in hospitals with hands-on executives, new study shows, Automated safety checklists prevent hospital-acquired infections, Stanford team finds and Reducing miscommunication in hospital patient transfers
Photo by CDC Global

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