Children in hospitals often have adverse events

Those younger than 1 year are at highest risk

According to new research from the Rockville, MD-based Agency for Healthcare Research and Quality (AHRQ), children in hospitals often experience adverse patient safety events (i.e., medical injuries or errors) in the course of their care, with those in vulnerable populations, including children younger than 1 year, at highest risk. The AHRQ report, Pediatric Patient Safety in Hospitals: A National Picture in 2000, is published in the June 2004 issue of Pediatrics.

The study of 5.7 million hospital discharge records for children younger than 19 from 27 states was drawn from the 2000 Healthcare Cost and Utilization Project State Inpatient Database. It 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.

Here are some of the key findings:

  • The study identified a total of 51,615 patient safety events involving children in hospitals during 2000.
  • Children up to 1 year old were consistently and significantly more likely to experience many of the events than older children, and children whose primary insurance was Medicaid also were more likely to experience such events.
  • 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.
  • 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 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 alone account for 4,483 deaths among hospitalized children in the year 2000.

The researchers used the recently developed patient safety indicators (PSIs) in identifying the reported trends.

"These are the first indicators that are applicable to both children and adults," says Marlene Miller, MD, director of quality and safety initiatives at Johns Hopkins Children’s Center in Baltimore, who led the research and who began developing the PSIs when she was at AHRQ.

"The earlier indicators we used in the 1990s, called the Complication Screening Program, could only be used for patients over 18," she explains. "We excluded this to make sure our definitions could be broadly applicable to children and adults — and in fact, there is one, birth trauma, that is specific only to kids."

Miller began developing the PSIs in the wake of the 1999 IOM report, To Err is Human, which pointed out the high cost of medical errors in terms of human lives.

"We realized that while we had many good measures of quality of care, we didn’t have very good measures on safety," she explains.

The work began as a research project, and as it evolved, AHRQ contracted with the University of California at San Francisco’s (UCSF) evidence-based practice center to take what Miller’s team had developed internally, to add some final touches and to run it by expert panels.

These administrative database tools "run on what [data] all hospitals churn," Miller explains. "Our goal was to create a set of algorithms that, when applied to the administrative data, identified issues everyone agrees should not have happened — like a foreign body left in a patient after a procedure."

She further explains the thought process: "Take post-op sepsis. If you are a trauma victim, thrown from a car, cut and bruised, and impaled on a tree, you’ve had a lot of unsterile things enter your body, so it’s not uncommon if you undergo surgery and develop an infection. In our cases, we limit post-op sepsis to elective surgery — the well patient who enters your doors for a pre-planned. You are also eliminated if you are immunosuppressed."

In other words, Miller summarizes, "We tailored the PSIs to solely identify cases everyone around the table agreed shouldn’t happen. (The PSIs are free from the AHRQ web site: www.ahrq.gov.)

Miller asserts that hospital quality managers are the right audience for this and other studies derived from the PSIs.

"Our whole goal is for [them to be used by] hospitals," she notes. "What we ran for this study was anonymized data, but an individual hospital can download these algorithms, run it on their own data, and they could actually find out the names of the patients."

For example, she says, if you found 10 cases of "foreign body left after procedure," you could pull the charts to determine commonalities there were among those procedures.

Using the PSIs can help you get to the root of safety problems much more quickly, she continues. "Say you had 30,000 charts last year. Most people have event rates in a given year between one to 10 or 10 to 20, so you have a small number of charts to pull."

Need More Information?

For more information, contact:

• Marlene Miller, MD, Director of Quality and Safety Initiatives, Johns Hopkins Children’s Center, CMSC 2-125, 600 N. Wolfe St., Baltimore, MD 21287. Phone: (443) 287-5365. Fax: (410) 955-0761. E-mail: mmille21@jhmi.edu.