Children more at risk from adverse events

Children in hospitals often experience adverse patient safety events such as medical injuries or errors in the course of their care, new research shows. Those in vulnerable populations, including children younger than 1 year old, are at highest risk, according to a study from the Agency for Health-care Research and Quality in Rockville, MD.

The research can be a good starting point for risk managers who want to reduce the risk of such adverse events but don’t know where to start, says Marlene R. Miller, MD, from Baltimore’s Johns Hopkins Children’s Center and the lead researcher. "There is an unending spectrum of ways to commit errors in hospitals, so where do you start?" she says. "This research gives you a hint at one group that we know is more vulnerable and could benefit from some added attention."

Patient Safety Indicators used

While the study gives an overall look at problem areas and vulnerable populations, Miller says it really should serve as an example of how a hospital can analyze its own data to zero in patient safety issues. The study, which uses the recently developed Patient Safety Indicators (PSIs) to focus on children in hospitals, examined 5.7 million hospital discharge records for children younger than age 19 from 27 states, drawn from the 2000 Healthcare Cost and Utilization Project State Inpatient Database.1

This is one of the first studies to quantify the impact of patient safety events on children in terms of excess hospital stays and charges as well as the increased risk of death among children due to medical errors.

In total, 51,615 patient safety events involving children in hospitals during 2000 were identified. Children up to 1 year old were consistently and significantly more likely to experience many of the events identified by the PSIs than older children, and children whose primary insurance was Medicaid also were more likely to experience several of the PSI events.

The prevalence of patient safety events resulting in injuries among children also had an impact on the length of stay, charges and the rate of in-hospital deaths. For example, infections resulting from medical care caused a 30-day increase in the average length of stay, and resulted in increased charges an average of more than $121,000 per discharge. In total, the combined excess charges for all PSI events are estimated to have exceeded $1 billion.

Postoperative respiratory failure increased the rate of deaths in hospitals by as much as 76%. The researchers estimate that if all deaths among pediatric patients who experience a medical injury are attributed to those injuries, then the records in their analysis account for 4,483 deaths among hospitalized children in the year 2000 alone.

Risk managers can use these findings to help them direct their efforts to reduce medical errors and improve patient safety among the youngest patients, Miller says. She found that the likelihood of a child experiencing a patient safety event varied greatly depending on the type of event. Some types of events were very uncommon, like postoperative hip fractures and transfusion reactions, both of which occurred less than once for every 10,000 discharges.

Others types of events, however, were very prevalent. The leading patient safety events were obstetric trauma among adolescent mothers, with and without forceps, vacuums, or other instruments, with rates of 2,152 and 1,072 per 10,000 discharges, respectively.

"The Patient Safety Indicators are a valuable tool for researchers to use in identifying the significant problems in patient safety experienced by hospitalized children on a national scale," Miller says. "The PSI data provide a road map for further research and action in pediatric patient safety."

Special risk up to 1 year old

Miller’s study revealed that children up to 1 year old were at particular risk for adverse events, and she says that may be reason for risk managers to pay special attention to that group. "Younger kids have much less resistance and ability to tolerate errors or abnormalities," she says. "Giving 10% extra medicine to you and me may not be much of a threat, but those younger kids’ livers are not able to metabolize as well and that can make them more vulnerable. Younger kids get liquid medicines more often, which means it has to be compounded and there’s more chance of getting the dosage wrong."

Children on Medicaid also experienced adverse events more frequently, which Miller says probably is related to the fact that they are more likely to be born to younger and more socioeconomically challenged mothers, which can result in less medical care and other factors that make the child less resilient when subjected to an error.

Miller suggests that risk managers can use the PSIs to analyze their own data and identify potential problem areas. "If a hospital has 5,000 discharges to look at, where do you start to look for problems?" she asks. "But if this analysis identifies 20 charts with adverse events that probably should not have occurred, that’s an excellent place to direct your energy and resources. That’s what we’re doing at four different hospitals I’m working with."

Pulling those 20 charts may not immediately identify the root causes of the problem, but they represent much more manageable number to study, Miller notes. For example, you could pull all the charts that indicate a foreign body unintentionally left in the patient. A study of those charts might reveal that most are catheter tips that keep breaking, and then that can lead to a solution, she says.

Also, she says that kind of hospital-specific data will get people’s attention more than generic information on a national level, particularly if you combine it with information about how many cases led to legal claims. "When you go in the board room and say, We need to do something because we had 10 kids with a foreign body left in them last year,’ people will sit up and listen to you," Miller says. "When you bring your own data, that’s incredibly motivating. You’re not talking about national data; you’re talking about kids at your own hospital."


1. Miller MR, Zhan C. Pediatric patient safety in hospitals: A national picture in 2000. Pediatrics 2004; 113:1,741-1,746.