… and failure to communicate effectively. … Burrus  S, Hall M, Tooley E, et al. Factors related to serious safety events in a children's hospital patient safety collaborative. Pediatrics. …

Imaging is an important tool in the pediatric emergency department to guide diagnosis and treatment. In this study, researchers analyzed more than 3.6 million emergency department visits for patients younger than 18 years to evaluate racial and ethnic differences in diagnostic imaging rates. One-third of visits by non-Hispanic white children included imaging, compared with 24% of visits by non-Hispanic Black and 26% of Hispanic children. Given the risks of both radiation exposure and missed diagnoses, strategies to mitigate these disparities must be investigated.

Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.

This study leveraged a multicenter collaborative approach to address the complex process of managing acute patient deteriorations. The authors conclude that wide-scale improvements take time, but the collaborative approach can accelerate such goals and foster a culture of safety.

Prescribing of antibiotics for non-bacterial illnesses remains very common in outpatient pediatrics. Unnecessary antibiotic prescribing can be associated with serious patient safety consequences, as discussed in an AHRQ WebM&M commentary.

This study describes the development and validation of the TeamSTEPPS Teamwork Attitudes Questionnaire, a survey instrument designed to measure attitudes toward teamwork in health care delivery. The TeamSTEPPS teamwork training program was developed as a collaboration between the Agency for Healthcare Research and Quality and the Department of Defense.

This study sought to characterize the incidence and types of adverse events in pediatric surgery patients, using measures (the National Surgical Quality Improvement Program and the AHRQ Patient Safety Indicators) originally developed for identifying adverse events in adults. The authors argue that applying adult measures to a pediatric population overestimates the incidence of adverse events.

The Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) have been widely used to identify patient safety events in adult populations. Pediatric-specific PSIs have recently been developed as well. This study used PSI data from more than 400,000 pediatric hospital admissions to estimate the impact on costs and hospital length of stay associated with inpatient adverse events. These data provide the first estimate of the economic impact of preventable adverse events in children's hospitals. Based on similar research in adults, the Centers for Medicare and Medicaid Services recently decided to stop reimbursing hospitals for costs associated with certain adverse events.

This AHRQ-funded study describes different approaches to analyzing administrative data, along with how these methods affect the interpretation of related findings. The authors use these methods to uncover characteristics associated with the occurrence of patient safety indicators.

The authors provide background on patient safety in intensive care units (ICUs) and suggest practical ways to improve care in the ICU.

Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.