Pediatric Adverse Events High, Unchanged, Study Finds

Troy Brown, RN

July 16, 2018

Adverse events (AEs) remain high among pediatric inpatients and are "substantially higher" among children in teaching hospitals and those with chronic conditions, a study has found. More than half of AEs were preventable.

"Although a growing body of literature has demonstrated substantial reductions in certain types of AEs in hospitals, it appears that additional efforts are needed to achieve improvements in the safety of all care for hospitalized children," write David C. Stockwell, MD, MBA, from Children's National Medical Center and the Division of Critical Care Medicine, Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, both in Washington, DC, and colleagues.

The researchers used the Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool to analyze randomly selected medical records of pediatric patients discharged from 16 Pediatric Research in Inpatient Settings Network hospitals located in all four major US geographic regions. They published  their findings online July 13 in Pediatrics on behalf of the GAPPS study group.

The GAPPS manual list includes 27 "triggers" found in medical records that suggest a patient may have experienced medical harm. For example, naloxone administration could indicate an opioid overdose caused by a prescribing error. The authors defined AEs as "unintended physical injury (resulting from or contributed to) by medical care that required additional monitoring, treatment, or hospitalization, or that resulted in death."

They randomly selected and reviewed 3790 records from January 2007 through December 2012. Overall, they identified 414 AEs (19.1 AEs per 1000 patient days; 95% confidence interval [CI], 17.2 - 20.9) and 210 preventable AEs (9.5 AEs per 1000 patient days; 95% CI, 8.2 - 10.8).

Hospital-acquired infections was the most common cause of AEs (77 AEs), followed by intravenous line complications (60 AEs), gastrointestinal harms (49 AEs), respiratory-related harms (53 AEs), and other causes (49 AEs).

On the basis of the National Coordinating Council for Medication Error Reporting and Prevention Index, 218 AEs (52.7%) were category E (contributed to or resulted in temporary patient harm and required intervention), and 146 (35.3%) were category F (contributed to or resulted in temporary patient harm and required initial or prolonged hospitalization).

Twelve percent of AEs were more severe: 5 (1.2%) AEs resulted in permanent harm (category G), 42 (10.1%) were life-threatening (category H), and 3 (0.7%) were fatal or contributed to a patient's death (category I).

On average, AE rates were higher at teaching hospitals than at nonteaching hospitals (26.2  vs 5.1 AEs per 1000 patient days; P < .001). The researchers note that children in teaching hospitals often have more complex medical needs; however, it is also possible that children receive safer care in nonteaching hospitals.

Pediatric patients with chronic conditions had higher AE rates than children who did not have a chronic condition (33.9 vs 14.0 AEs per 1000 patient days, P < .001).

Slightly more than half of the AEs (210; 50.7%) were preventable, with 9.5 preventable AEs (95% CI, 8.2 - 10.8) per 1000 patient days and 5.5 preventable AEs (95% CI, 4.8 - 6.3) per 100 admissions.

AE rates did not change significantly over time in multivariate analyses adjusted for potential confounders, including chronic condition indicators, hospital type, age, sex, and insurance. "Poisson regression in which hospital-level clustering and changes over time were accounted for revealed a nonsignificant 1.2% increase per year in rate of AEs per 1000 patient days (relative increase in risk per year = 1.012 [95% CI 1.00–1.03]; P = .10)…and AEs per 100 admissions likewise did not change (risk factor = 1.00 [95% CI 0.98–1.017]; P = .998)," the authors write.

Trigger Tools May Still Miss Some Adverse Events

The "findings are sobering," write Ricardo A. Quinonez, MD, Section of Pediatric Hospital Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, and Alan R. Schroeder, MD, Department of Pediatrics, College of Medicine, Stanford University, Palo Alto, California, in an accompanying editorial.

The lack of change in the 5-year period is different from findings in other analyses that did find some improvements, but the types of AEs studied were also different. Previous studies focused solely on hospital-acquired conditions as opposed to the more inclusive AEs measured by GAPPS.

"Tools that use 'triggers,' including some that are pediatric-specific, are used to actively detect AEs via automated processes and have been found to detect errors at a higher rate than the usual passive methods," Quinonez and Schroeder write.

Yet even the GAPPS trigger tool can miss many of them, the editorialists note. "GAPPS uses triggers that suggest an AE occurred (eg, naloxone administration).‍ However, children in the hospital setting are exposed to other more insidious harms. The harm from unnecessary care delivered to children may not be as easy to detect, because the effects may be subtle or may only be apparent through long-term outcomes," Quinonez and Schroeder explain.

For example, the effects of unnecessary computed tomography scans may take decades to become evident. Unnecessary testing can also "unleash a prolonged diagnostic cascade when subtle abnormalities are detected, but would not be considered an AE."

"Given that even safely delivered health care can cause harm, we agree with recent calls to label unnecessary care as a reportable safety event.‍ Only by identifying all sources of harm and equally weighing errors of omission with errors of commission can we hope for a future in which hospitals are truly safe," the editorialists conclude.

The authors and editorialists have disclosed no relevant financial relationships.

Pediatrics. Published online July 13, 2018. Abstract, Editorial

For more news, join us on Facebook and Twitter


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.