Factors Related to Serious Safety Events in a Children's Hospital Patient Safety Collaborative

Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety Incidents

BACKGROUND

Paediatric patients are prone to medication errors, but an in-depth understanding of errors involving high-alert medications remains limited.

OBJECTIVE

We aimed to investigate incident reports involving high-alert medications to describe medication errors, error chains and stages of the medication management and use process where the errors occur in paediatric hospitals.

METHODS

A retrospective document analysis of self-reported medication safety incidents in a paediatric university hospital in 2018-20. The incident reports involving high-alert medications were investigated using an inductive qualitative content analysis and quantified (frequencies and percentages). A systems approach to medication risk management based on the Theory of Human Error was applied.

RESULTS

Altogether, 560 medication errors were identified within the study sample (n = 426 incident reports). Most medication errors were associated with administration (43.1 %, n = 241/560) and prescribing (25.2 %, n = 141/560). Error chains involving two to four medication errors in one or more stages of the medication management and use process were present in 26.1% (n = 111/426) of reports, most of which originated from prescribing (62.2%; n = 69/111). The medication errors (n = 560) were classified into 14 main categories, the most common of which were wrong dose (13.9%; n = 78/560), omission of a drug (12.9%; n = 72/560) and documentation errors (10.0%; n = 56).

CONCLUSIONS

Paediatric medication error chains often start from prescribing and pass through the medication management and use process. Systemic defences are especially needed for manual tasks leading to wrong doses, drug omission and documentation errors. Intravenous medications and chemotherapeutic agents, optimising drug formularies and handling, and high-alert drug use at home require further actions in paediatric medication risk management.

Pressure injury prevention: An educational framework to improve action planning

ABSTRACT

ECRI and the Institute for Safe Medication Practices (ISMP) Patient Safety Organization (PSO) convened an interdisciplinary pressure-injury-prevention safety collaborative to strengthen pressure injury assessment, prevention, and treatment planning. Several teams met over 5 months in 2023 to share knowledge and performance improvement tools. This article discusses the safety collaborative, which provided a learning-system platform for participating teams to develop and share improvement plans under the protection of the PSO and to strengthen their pressure-injury-related action plans.

Examining Patient Safety Events Using the Behaviour Change Wheel: A Cross-Sectional Analysis

BACKGROUND

Precursor-level safety events (PSEs) pose greater patient risk than no-harm events but are not as severe as serious safety events. Despite their potential for harm, the underlying determinants associated with PSEs are poorly understood. This study aimed to use a behavior change framework to understand the underlying determinants of PSEs and whether associated action items aligned with the behavior.

METHODS

This cross-sectional study took place in a maternal/pediatric hospital. A total of 58 prerecorded PSEs were analyzed using the Behaviour Change Wheel (BCW); a behavioral framework that identifies sources of behavior and proposes intervention types that address said behavior. Researchers and clinicians independently coded each PSE's underlying determinant and action items using the relevant components of the BCW. The types and frequency of underlying behavioral determinants and intervention types for each PSE were documented. A matrix, based on the BCW, reflected how often the underlying behavior aligned with the corresponding action item.

RESULTS

Of the 58 PSEs, six behavioral determinants and seven intervention types were identified. Environmental context/resources was the behavioral determinant coded most often (25.4%); education was the most common intervention type (45.8%). Several underlying determinants (24.6%) and action items (8.3%) received no code due to limited information. Based on the BCW matrix, 34.2% of behavioral determinants were addressed with interventions that would target the underlying behavior, while 37.8% did not align, and 28.1% could not be coded due to missing behavioral information.

CONCLUSION

This study identified poor alignment between types of interventions and underlying determinants in more than one third of analyzed PSEs. This included using educational interventions in about 50% of events, despite this type of intervention being ineffective for most of the coded behaviors. Further, alignment of many safety events could not be determined due to limited reported information. This highlights a need to design more systematic, behavior-informed approaches to reporting PSEs and identifying interventions to effectively change behavior.

Usability Testing of Situation Awareness Clinical Decision Support in the Intensive Care Unit

OBJECTIVE

 Our objective was to evaluate the usability of an automated clinical decision support (CDS) tool previously implemented in the pediatric intensive care unit (PICU) to promote shared situation awareness among the medical team to prevent serious safety events within children's hospitals.

METHODS

 We conducted a mixed-methods usability evaluation of a CDS tool in a PICU at a large, urban, quaternary, free-standing children's hospital in the Midwest. Quantitative assessment was done using the system usability scale (SUS), while qualitative assessment involved think-aloud usability testing. The SUS was scored according to survey guidelines. For think-aloud testing, task times were calculated, and means and standard deviations were determined, stratified by role. Qualitative feedback from participants and moderator observations were summarized.

RESULTS

 Fifty-one PICU staff members, including physicians, advanced practice providers, nurses, and respiratory therapists, completed the SUS, while ten participants underwent think-aloud usability testing. The overall median usability score was 87.5 (interquartile range: 80-95), with over 96% rating the tool's usability as "good" or "excellent." Task completion times ranged from 2 to 92 seconds, with the quickest completion for reviewing high-risk criteria and the slowest for adding to high-risk criteria. Observations and participant responses from think-aloud testing highlighted positive aspects of learnability and clear display of complex information that is easily accessed, as well as opportunities for improvement in tool integration into clinical workflows.

CONCLUSION

 The PICU Warning Tool demonstrates good usability in the critical care setting. This study demonstrates the value of postimplementation usability testing in identifying opportunities for continued improvement of CDS tools.

Medication errors related to high-alert medications in a paediatric university hospital - a cross-sectional study analysing error reporting system data

BACKGROUND

Paediatric patients are prone to medication errors, and only a few studies have explored errors in high-alert medications in children. The present study aimed to investigate the prevalence and nature of medication errors involving high-alert medications and whether high-alert medications are more likely associated with severe patient harm and higher error risk classification compared to other drugs.

METHODS

This study was a cross-sectional report of self-reported medication errors in a paediatric university hospital in 2018-2020. Medication error reports involving high-alert medications were investigated by descriptive quantitative analysis to identify the prevalence of different drugs, Anatomical Therapeutic Chemical groups, administration routes, and the most severe medication errors. Crosstabulation and Pearson Chi-Square (χ2) tests were used to compare the likelihood of more severe consequences to the patient and higher error risk classification between medication errors involving high-alert medications and other drugs.

RESULTS

Among the reported errors (n = 2,132), approximately one-third (34.8%, n = 743) involved high-alert medications (n = 872). The most common Anatomical Therapeutic Chemical subgroups were blood substitutes and perfusion solutions (B05; n = 345/872, 40%), antineoplastic agents (L01; n = 139/872, 16%), and analgesics (N02; n = 98/872, 11%). The majority of high-alert medications were administered intravenously (n = 636/872, 73%). Moreover, IV preparations were administered via off-label routes (n = 52/872, 6%), such as oral, inhalation and intranasal routes. Any degree of harm (minor, moderate or severe) to the patient and the highest risk classifications (IV-V) were more likely to be associated with medication errors involving high-alert medications (n = 743) when compared to reports involving other drugs (n = 1,389).

CONCLUSIONS

Preventive risk management should be targeted on high-alert medications in paediatric hospital settings. In these actions, the use of intravenous drugs, such as parenteral nutrition, concentrated electrolytes, analgesics and antineoplastic agents, and off-label use of medications should be prioritised. Further research on the root causes of medication errors involving high-alert medications and the effectiveness of safeguards is warranted.

Clinical Pathway Adherence and Missed Diagnostic Opportunities Among Children with Musculoskeletal Infections

INTRODUCTION

Clinical care pathways (CPs) integrate best evidence into the local care delivery context to promote efficiency and patient safety. However, the impact of CPs on diagnostic performance remains poorly understood. The objectives of this study were to evaluate adherence to a musculoskeletal infection (MSKI) diagnostic CP and identify recurrent failure points leading to missed diagnostic opportunities (MDOs).

METHODS

Retrospective chart review was performed from January 2018 to February 2022 for children 6 months to 18 years of age who had an unplanned admission for MSKI after being evaluated and discharged from the pediatric emergency department (PED) for related complaints within the previous 10 days. MDOs were identified using the Revised Safer Dx. Demographic and clinical characteristics of children with and without MDOs were compared using bivariate descriptive statistics. An improvement team reviewed the diagnostic trajectories of MDOs for deviations from the MSKI CP and developed a fishbone diagram to describe contributing factors to CP deviations.

RESULTS

The study identified 21 children with and 13 children without MSKI-associated MDOs. Children with MDOs were more likely to have an initial C-reactive protein value > 2 mg/dL (90.0% vs. 0%, p = 0.01) and returned to care earlier than children without MDOs (median 2.8 days vs. 6.7 days, p = 0.004). Factors contributing to MDOs included failure to obtain screening laboratory tests, misinterpretation of laboratory values, failure to obtain orthopedic consultation, and failure to obtain definitive imaging.

CONCLUSION

Several recurrent deviations from an MSKI diagnostic CP were found to be associated with MDOs. Future quality improvement efforts to improve adherence to this MSKI CP may prevent MDOs.

Variability in Serious Safety Event Classification among Children's Hospitals: A Measure for Comparison?

Introduction

Hospitals have no standard for measuring comparative rates of serious safety events (SSE). A pediatric hospital safety collaborative has used a common definition and measurement system to classify SSE and calculate a serious safety event rate. An opportunity exists to evaluate the use of this measurement system.

Methods

A web-based survey utilizing 7 case vignettes was sent to 132 network hospitals to assess agreement in classifying the vignettes as SSEs. Respondents classified the vignettes according to the taxonomy used at their respective organizations for deviations and SSE classification.

Results

Of the 82 respondents, 67 (82%) utilized the same SSE classification system. Respondents did not assess deviations for 2 of the 7 vignettes, which had clear deviations. Of the remaining 5 vignettes, 3 had a substantial agreement of deviation (>85%, Gwet's AC ≥ 0.68), and 2 had fair agreement (<70%, Gwet's AC ≤ 0.39). Four of the 7 vignettes had a substantial agreement on SSE classification (>80%; Gwet's AC ≥ 0.80), and 3 had slight to moderate agreement (<70%, Gwet's AC ≤ 0.78).

Conclusions

Results demonstrated agreement and variability in determining deviation and SSE classification in the 7 vignettes. Although the SSE methodology and metric used by participant pediatric hospitals yields generally similar review results, one must be cautious in using the SSE rate to compare patient safety outcomes across different hospitals.