Reducing Errors and Promoting Safety in Pediatric Emergency Care

A Grounded Theory Qualitative Analysis of Interprofessional Providers' Perceptions on Caring for Critically Ill Infants and Children in Pediatric and General Emergency Departments

OBJECTIVE

The objective of this study was to explore pediatric emergency department (PED) and general emergency department (GED) providers' perceptions on caring for critically ill infants and children.

METHODS

This study utilized qualitative methods to examine the perceptions of emergency department providers caring for critically ill infants and children. Teams of providers participated in 4 in situ simulation cases followed by facilitated debriefings. Debriefings were recorded and professionally transcribed. The transcripts were reviewed independently and followed by group coding discussions to identify emerging themes. Consistent with grounded theory, the team iteratively revised the debriefing script as new understanding was gained. A total of 188 simulation debriefings were recorded in 24 departments, with 15 teams participating from 8 PEDs and 32 teams from 16 GEDs.

RESULTS

Twenty-four debriefings were audiotaped and professionally transcribed verbatim. Thematic saturation was achieved after 20 transcripts. In our iterative qualitative analysis of these transcripts, we observed 4 themes: (1) GED provider comfort with algorithm-based pediatric care and overall comfort with pediatric care in PED, (2) GED provider reliance on cognitive aids versus experience-based recall by PED providers, (3) GED provider discomfort with locating and determining size or dose of pediatric-specific equipment and medications, and (4) PED provider reliance on larger team size and challenges with multitasking during resuscitation.

CONCLUSIONS

Our qualitative analysis produced several themes that help us to understand providers' perceptions in caring for critically ill children in GEDs and PEDs. These data could guide the development of targeted educational and improvement interventions.

[Experience of implementing the ISO 9001:2015 standard for the accreditation of a paediatric hospital emergency department]

OBJECTIVE

The aim of this paper was to describe the process for accrediting a paediatric hospital emergency department to ISO 9001:2015 standards. The implementation process began in February 2015 and lasted 18months.

MATERIAL AND METHODS

The project started with the decision by the Head of Department to improve service quality. A Quality Committee was established with representation of the medical, nursing and administrative staff. Training sessions were held on quality management systems and ISO standards for employees. A meeting took place among members of the Emergency Department to define the main processes, and 14 were identified, documented and included in the processes map. Workgroups were then created to review and redesign the medical and nurse protocols.

RESULTS

Thirty-five medical and fifteen nursing protocols were incorporated into the management system, and quality indicators were established that allowed the whole process to be monitored. A risk register was created to record identified risks, their severity, likelihood of occurrence, and actions taken to prevent or reduce those risks. The Emergency Department underwent an external audit during June 2016, and was certified to the requirements demanded by the international ISO 9001:2015 standard.

CONCLUSIONS

The conclusion is that implementation of a quality management system on ISO and its certification is completely achievable, and has contributed to better patient management.

Patient safety in ambulance services: a scoping review

Background

The role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.

Objective

To identify and map available evidence relating to patient safety when using ambulance services.

Design

Mixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.

Setting and participants

Ambulance services, their staff and service users in UK.

Data sources

A wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.

Review methods

Data were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.

Results

We identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.

Conclusion

Patient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Why and when to use CT in children: perspective of a pediatric emergency medicine physician

The Emergency Department is a risk-laden environment for clinicians caring for children. A number of factors can increase the risk of medical errors and adverse events, including lack of standardized medication dosing because of size variation in the pediatric age range, unique physical and developmental characteristics of children that affect treatment strategies, and the inability of young or non-verbal children to provide a medical history or to clearly communicate pain and other symptoms. The Emergency Department (ED) setting is often hectic and chaotic, with lots of interruptions. Many EDs lack the pediatric-specific supplies deemed essential for managing pediatric emergencies, and long hours or overnight shifts, while necessary for maintaining 24-hour emergency services, can cause provider fatigue that can lead to increased medical errors. It is in this environment that ED physicians make decisions about the use of CT scans in children, often without evidence-based guidelines to help them weigh risks and benefits. Although recent efforts have raised the awareness of the risk of exposure to radiation, many pediatric providers and families lack adequate information to guide decisions about the use of CT. Pediatricians and emergency physicians need to collaborate with radiologists to maintain current knowledge of the risks and benefits of CT scans, to advocate for pediatric protocols and evidence-based guidelines, and to engage families in decisions regarding the evaluation and treatment of pediatric patients in the Emergency Department.

Telemedicine consultations and medication errors in rural emergency departments

OBJECTIVE

To compare the frequency of physician-related medication errors among seriously ill and injured children receiving telemedicine consultations, similar children receiving telephone consultations, and similar children receiving no consultations in rural emergency departments (EDs).

METHODS

We conducted retrospective chart reviews on seriously ill and injured children presenting to 8 rural EDs with access to pediatric critical care physicians from an academic children's hospital. Physician-related ED medication errors were independently identified by 2 pediatric pharmacists by using a previously published instrument. The unit of analysis was medication administered. The association of telemedicine consultations with ED medication errors was modeled by using hierarchical logistic regression adjusting for covariates (age, risk of admission, year of consultation, and hospital) and clustering at the patient level.

RESULTS

Among the 234 patients in the study, 73 received telemedicine consultations, 85 received telephone consultations, and 76 received no specialist consultations. Medications for patients who received telemedicine consultations had significantly fewer physician-related errors than medications for patients who received telephone consultations or no consultations (3.4% vs. 10.8% and 12.5%, respectively; P < .05). In hierarchical logistic regression analysis, medications for patients who received telemedicine consultations had a lower odds of physician-related errors than medications for patients who received telephone consultations (odds ratio: 0.19, P < .05) or no consultations (odds ratio: 0.13, P < .05).

CONCLUSIONS

Pediatric critical care telemedicine consultations were associated with a significantly reduced risk of physician-related ED medication errors among seriously ill and injured children in rural EDs.

Perioperative pharmacology: a framework for perioperative medication safety

Learning pharmacology is a critical element of any health care practitioner's education to ensure quality and safety in perioperative care. The medication-use process and safe medication use are two important principles that contribute to the safe use of pharmacological agents in perioperative clinical practice. The medication-use process consists of procuring, prescribing, transcribing, dispensing, administering, and monitoring; however, variations in the medication-use process result from demands unique to the perioperative environment, and these variations can sometimes bypass the safety nets within the system. Understanding these variances will help perioperative practitioners recognize threats to patient safety and help ensure the patient's well-being. Responsibilities of a safe medication-use system include assuring the public that practitioners use medications efficiently, safely, and effectively, and fully document all medications administered.

Efficiency and economic benefits of a payer-based electronic health record in an emergency department

OBJECTIVES

The objective was to evaluate the use of a payer-based electronic health record (P-EHR), which is a clinical summary of a patient's medical and pharmacy claims history, in an emergency department (ED) on length of stay (LOS) and plan payments.

METHODS

A large urban ED partnered with the dominant health plan in the region and implemented P-EHR technology in September 2005 for widespread use for health plan members presenting to the ED. A retrospective observational study design was used to evaluate this previously implemented P-EHR. Health plan and electronic hospital data were used to identify 2,288 ED encounters. Encounters with P-EHR use (n = 779) were identified between September 1, 2005, and February 17, 2006; encounters from the same health plan (n = 1,509) between November 1, 2004, and March 31, 2005, were compared. Outcomes were ED LOS and plan payment for the ED encounter. Analyses evaluated the effect of using the P-EHR in the ED setting on study outcomes using multivariate regressions and the nonparametric bootstrap.

RESULTS

After covariate adjustment, among visits resulting in discharge (ED-only), P-EHR visits were 19 minutes shorter (95% confidence interval [CI] = 5 to 33 minutes) than non-P-EHR visits. Among visits resulting in hospitalization, the P-EHR was associated with an average 77-minute shorter ED LOS (95% CI = 28 to 126 minutes), compared to non-P-EHR visits. The P-EHR was associated with an average of $1,560 (95% CI = $43 to $2,910) lower total plan expenditures for hospitalized visits. No significant difference in total payments was observed among discharged visits.

CONCLUSIONS

In the study ED, the P-EHR was associated with a significant reduction in ED LOS overall and was associated with lower plan payments for visits that resulted in hospitalization.

Time motion study in a pediatric emergency department before and after computer physician order entry

STUDY OBJECTIVE

To determine the effect of computer physician order entry on pediatric emergency department (ED) care providers allocation of time. We seek to determine whether the increase in time by ED care providers on the computer will decrease time spent with patients.

METHODS

This was a before-and-after observational time-and-motion study conducted at an urban pediatric ED. Observers recorded how caregivers allocated their time during 180-minute observation periods at 30-second increments the summers before after computer physician order entry introduction. Time on the computer was recorded in seconds. Observations were placed into 3 categories (direct patient care, indirect patient care, other), each with its own subcategories.

RESULTS

For attending physicians, median computer time increased from 5.0 minutes before computer physician order entry to 9.5 minutes after computer physician order entry (P=.01). For resident physicians, median computer time increased from 5.5 minutes before computer physician order entry to 14.3 minutes after computer physician order entry (P=.001). For nurses, time on the computer was not significantly different before and after computer physician order entry (P=.15), although it appears there was still some change in time allocation. After computer physician order entry, nurses' talking with staff about patient care decreased from 24.5 minutes to 13.3 minutes (P=.01). Computer physician order entry did not decrease time with patients for any of the caregiver types.

CONCLUSION

The addition of computer physician order entry to a pediatric ED increases time spent on the computer by both attending and resident physicians but not for emergency nurses. This additional time on the computer is allocated from nonpatient care activities. The addition of computer physician order entry decreases nurses' time talking with other staff for patient care.

Impact of a patient-centered technology on medication errors during pediatric emergency care

OBJECTIVE

The aim of this study was to determine the impact of a patient-centered health information technology (HIT) on the error rate for ordering and prescribing of medications during emergency pediatric care.

METHODS

We conducted a quasi-experimental intervention study by using control and intervention periods to evaluate the effect on medication ordering and prescribing from a patient-centered HIT designed to enhance communication between parents and emergency clinicians during emergency care. Parent-child dyads presenting to 2 emergency department (ED) sites with complaints of fever, asthma, head trauma, otalgia, and dysuria were eligible. During intervention periods, parents used the HIT to enter data on symptoms and medication-related history; a printout provided recommendations to clinicians. Data on errors/adverse drug events were collected via record reviews and phone interviews with parents. The primary outcome was the number of medication errors in orders or prescriptions for drugs targeted by the HIT.

RESULTS

Of 2002 parent-child dyads screened, 1810 (90%) were eligible, 1411 of 1810 (78%) were enrolled, and 1410 analyzed; 1097 subjects had a total of 2234 orders or prescriptions written. Of these events, 1289 of 2234 (58%) were associated with at least 1 error. Of the 1755 errors discovered, 232 errors were serious and preventable. Among 654 patients exposed to medications targeted by the HIT, the number of errors per 100 patients during control versus intervention periods was not significantly different (173 vs 134 with both sites combined; P = .35.)

CONCLUSION

The patient-centered HIT demonstrated minimal impact on medication errors during ED care.

Patient safety in the pediatric emergency care setting

Patient safety is a priority for all health care professionals, including those who work in emergency care. Unique aspects of pediatric care may increase the risk of medical error and harm to patients, especially in the emergency care setting. Although errors can happen despite the best human efforts, given the right set of circumstances, health care professionals must work proactively to improve safety in the pediatric emergency care system. Specific recommendations to improve pediatric patient safety in the emergency department are provided in this policy statement.

Emergency department overcrowding and children

Emergency department (ED) overcrowding has been a serious issue on the national agenda for the past 2 decades and is rapidly becoming an increasingly significant problem for children. The goal of this report is to focus on the issues of overcrowding that directly impact children. Our findings reveal that although overcrowding seems to affect children in ways similar to those of adults, there are several important ways in which they differ. Recent reports document that more than 90% of academic emergency medicine EDs are overcrowded. Although inner-city, urban, and university hospitals have historically been the first to feel the brunt of overcrowding, community and suburban EDs are now also being affected. The overwhelming majority of children (92%) are seen in general community EDs, with only a minority (less than 10%) treated in dedicated pediatric EDs. With the exception of patients older than 65 years, children have higher visit rates than any other age group. Children may be at particularly increased risk for medical errors because of their inherent variability in size and the need for age-specific and weight-based dosing. We strongly recommend that pediatric issues be actively included in all future aspects of research and policy planning issues related to ED overcrowding. These include the development of triage protocols, clinical guidelines, research proposals, and computerized data monitoring systems.

Pediatric patient safety in the prehospital/emergency department setting

The unique characteristics of the pediatric population expose them to errors in the emergency department (ED) with few standard practices for the safety of care. Young children and high-acuity patients are at increased risk of adverse events both in the prehospital and ED settings. We provide an overview of the problems and possible solutions to the threats to pediatric patient safety in the ED. Endorsing a culture of safety and training to work in a team are discussed. Medication errors can be reduced by using organizational systems, and manufacturing and regulatory systems, by educating health care providers, and by providing caregivers tools to monitor prescribing. The consensus is that a safe environment with a high quality of care will reduce morbidity and mortality in ED pediatric patients.

Intralipid medication errors in the neonatal intensive care unit

These findings suggest that most intralipids errors occur during the administration phase. This complex process can generate high opportunities for error directly related to the use of IV pumps. Nursing staff members are prone to making dosing errors while accurately programming the infusion devices, especially during times of high workload. The evening hours around shift change appeared most vulnerable to such errors occurring. A further analysis to include error rates as a function of error opportunities is critical. The tracking and tallying of such opportunity for error can be accomplished using smart pump technology. A detailed analysis of the existing intralipid administration workflow process will guide the overall strategy of an error prevention plan. Understanding the nursing workload as a function of time of day and census is essential. These mission-critical tasks often require the hard work of a dedicated task force, the commitment of the hospital leadership, and cooperation from the health care providers.

Evaluation of the impact of a paediatric procedural sedation credentialing programme on quality of care

OBJECTIVES

The aim of the present study is to describe changes in documentation, risk assessment and patient care resulting from implementation of a credentialing process for medical and nursing staff in paediatric procedural sedation (PPS) in two EDs - one an urban mixed ED and the other a specialist paediatric ED.

METHODS

Chart review of 100 patients undergoing PPS prior to and 100 patients following introduction of the PPS programme. Information was extracted from medical records and sedation checklists. Demographics, drugs used, procedure performed and elements of the pre-procedural, intra-procedural and post-procedural care were compared pre- and post implementation of the PPS programme.

RESULTS

Significant improvements in the post-implementation period compared with pre-implementation were seen in: frequency of documentation of informed consent (87 vs 15%, P < 0.0001); evidence of performance of a pre-procedural risk assessment (87 vs 1%, P < 0.0001); and appropriate recording of vital signs (58 vs 27%, P < 0.0001). Improvements were also noted in documentation of weight, allergies, fasting status and recording of drug orders. There were no adverse events recorded in the pre-programme period and 6 recorded in the post-programme period.

CONCLUSION

The implementation of a PPS credentialing programme into these two EDs resulted in significant improvements in risk assessment, monitoring and documentation of important information related to safe PPS. These improvements should result in improved quality and safety of PPS.

Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children

OBJECTIVE

No data exist on parental preferences for disclosure, reporting, and seeking legal action after errors in the care of their children are disclosed. This study examined parental preferences for error disclosure and reporting; responses to error disclosure; and preferences and responses by race/ethnicity, gender, age, and insurance.

METHODS

A 4-scenario survey instrument portraying a range of medical error was provided to a convenience sample of parents who presented with children to an emergency department. Parents were asked to categorize the error, express preferences for disclosure and reporting, and then report how they expected to respond with and without disclosure. Basic demographics were collected also. Bivariate analyses of demographics were performed with Fisher's exact tests, analysis of scenario responses was performed with Somers' D, and the independent effects of the study variables were assessed with a generalized estimating equation.

RESULTS

Research assistants approached 661 parents; 499 participated (75% response rate). Of all scenarios presented to the parents, they judged 54% of the scenarios as severe, 99% wanted disclosure, 39% wanted the error reported to a disciplinary body, and 36% were less likely to seek legal action if the error was disclosed by the physician. In multivariate modeling, severity was associated with desire for disclosure, reporting, and change in likelihood of legal action with disclosure.

CONCLUSIONS

Regardless of severity, parents want to be informed of error. Educational interventions to improve error disclosure should emphasize the uniformity of parental preferences for disclosure, reporting, and the decreased likelihood of legal action when errors are disclosed than if discovered through other means.