While adverse events (AE) in pediatric emergency departments are rare, the majority are considered preventable. This study reports on the proportion of pediatric patients experiencing an AE within 21 days of an emergency department visit, whether the AE may have been preventable, and the type of AE (e.g., management, diagnostic). Results show 3% of children experienced at least one AE, most of which were preventable.

Adverse drug events (ADEs) are an important cause of hospitalizations in older adults. Based on data from the OPERAM trial, this study explored the accuracy of triggers for identifying medication-related hospital admissions in older adults. Triggers were related to diagnoses (e.g., falls, bleeding, thromboembolic events), laboratory values (e.g., hypo- or hyperglycemia) and other factors (e.g., mention of an ADE in the patient record, abrupt medication discontinuation). Among 1,235 included hospitalizations, 58% cases had at least one trigger; medication-related admissions were adjudicated in 72% of these cases.

Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.

Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.    

Morbidity and mortality (M&M) conferences are designed to review adverse events. They are one method by which physicians undergo peer review to evaluate their performance and can allow health systems to identify potential avenues for improving patient safety. A survey of pediatric surgeons found that while the M&M participation was high, few believed the process results in practice changes or preventing future events. M&Ms considered most effective had a structured approach, were data driven with loop closure, emphasized multidisciplinary participation, and served as an educational forum.

This direct observation study examined maternal and neonatal care at 10 labor and delivery units. Investigators uncovered three environmental needs that impact safety: rapid access to blood products, space for neonatal resuscitation, and organization and availability of equipment and supplies. They conclude that applying design thinking to physical space could improve maternal and neonatal safety.

Research has shown that the effectiveness of surgical safety checklists in improving patient outcomes is mixed and may depend in part on implementation as well as providers' attitudes toward the importance of such checklists. In this survey study involving pediatric surgeons, 94% reported using surgical safety checklists but just 55% reported that they perceived such checklists to improve safety.

… Pronovost PJ; Sutcliffe KM; Kasda EM; Maragakis LL; Paine L; Sawyer MD; Winner L. …

This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.

Intravenous medication administration errors related to smart pumps can compromise patient safety. Prior research has shown that such errors are common and often involve incorrect dosing and workarounds. Researchers describe the development and implementation of a multicomponent safety intervention bundle developed to reduce medication administration errors associated with smart pump use. Although both the overall error rate and medication error rate per 100 medication administrations decreased, the intervention did not lead to a reduction in the rate of potentially harmful errors. A past PSNet perspective discussed the use of smart pumps to improve safety.

In light of recent expert analysis and improvement work, the concept of treating diagnosis as team activity is gaining acceptance. This review describes a framework for engaging nurses in the diagnostic process to enhance multidisciplinary teamwork and patient involvement. The authors suggest improvements in health care culture is required to implement the recommended changes, which include a focus on creating opportunities for shifting the process to be more patient centered.

Weight-based dosing errors can lead to adverse drug events. This retrospective study found that weight-related errors are rare but did lead to medication dosing errors and potential for harm. This finding underscores the need to address weight-based dosing on a systems level.

Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.

High reliability organizations embrace strategies to actively reduce errors and accidents. This commentary outlines a framework that focuses on integrating competencies at all levels of the health care workforce across the organization to support high reliability.

Programs to disclose errors and offer compensation, known as communication-and-resolution programs, have been shown to reduce malpractice claims. This pre–post study found that the growth of diagnostic testing for chest pain slowed after implementation of a communication-and-resolution program. The authors suggest further study to determine whether these results represent an appropriate reduction in unnecessary testing.

Prior research suggests that polypharmacy in patients with dementia may increase the risk of functional decline. This retrospective cohort study found that veterans with dementia who sought care from both within the Department of Veterans Affairs (VA) and from other health systems were more likely to receive prescriptions for potentially unsafe medications than those who sought care only within the VA system.

Research has demonstrated that disclosing errors to patients results in fewer malpractice claims, but such discussions do not always take place. This observational study described the effect of implementing the AHRQ Communication and Optimal Resolution (CANDOR) toolkit, an intervention bundle intended to support error disclosure, at a single health system. The investigators found that incident reports increased, suggesting that more safety problems were identified and reported. Also, the number of malpractice claims, along with their resultant costs, decreased significantly. Using an interrupted time series design, they established that these outcomes persisted more than 7 years after the program was introduced. The authors suggest that such programs can result in significant cost savings to health systems. A past PSNet perspective discussed error disclosure in health care.

Readmissions to the hospital are considered a marker of patient safety, and hospitals with high readmission rates are subject to reduced Medicare reimbursements. The extent to which readmissions are preventable remains controversial. Investigators examined 300 pediatric readmissions at a single hospital with input from inpatient providers, primary care providers, patients, family members, and medical records. They determined that approximately 30% of readmissions were preventable. Both patient-related factors such as parental anxiety and hospital-related factors such as hospital-acquired conditions contributed to preventable readmissions. The authors emphasize the importance of interviewing patients and family members as well as medical providers to better characterize the preventability of readmissions. They suggest that identifying factors associated with preventable readmissions will lead to readmission reduction strategies. Multiple strategies targeting the different contributing factors will likely be needed. A past PSNet interview reflected on the challenge of preventing readmissions.