Child-Specific Risk Factors and Patient Safety

Woods, Diana Lynn; Holl, Jane L.; Shonkoff, Jack P.; Mehra, Munisha; Ogata, Edward S.; Weiss, Kevin B.

doi:10.1097/01209203-200503000-00006

Cited by 30 publications

(19 citation statements)

References 9 publications

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“…Similar findings with respect to severity have been reported with 10% of AEs classified as severe in one study of harm in a paediatric intensive care unit 10. A study of AEs in hospitalised children reported that clinicians do not always recognise harm, even when the consequences to the child are severe 30. In this study, multiple AEs were relatively common, with 37% of those experiencing harm suffering two or more AEs in the same admission, far higher than in previous studies 8 25…”

Section: Discussionsupporting

confidence: 76%

Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool

et al. 2014

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The measurement and examination of adverse events (AEs) that occur in children during hospital admissions is essential if we are to prevent, reduce or ameliorate the harm experienced. The UK Paediatric Trigger Tool (UKPTT) is a method of retrospective case note review that measures harm in hospitalised children.ObjectivesTo examine the harm resulting from the processes of healthcare in hospitalised children from centres providing data to the National Health Service (NHS) Institute UKPTT data portal, to understand the positive predictive values of triggers and to make recommendations for the further development of the trigger tool.Setting25 hospitals across the UK, including secondary, tertiary and quaternary paediatric centres.ParticipantsRandomly selected children who were admitted to hospital for longer than 24 h.Outcome measuresThe primary outcome measure was the rate of harm (the percentage of children experiencing one or more AEs during a hospital admission). Secondary measures were the severity of harm and performance of triggers.ResultsData from 3992 patient admissions were reviewed across the hospitals and submitted to the trigger tool portal from February 2008 to November 2011. At least one AE was reported for 567 (14.2%) patients, with 211 (5.3%) experiencing more than one event. There were 1001 AEs identified. Where harm occurred, it was considered temporary for 923 (92.2%) AEs; however, 43 (4.3%) AEs resulted in the need for life-sustaining interventions, 18 (1.8%) AEs led to permanent harm and for 17 children (1.7% of AEs) the AE was believed to have contributed to death.ConclusionsThere is a significant, measurable level of harm experienced by children admitted to hospitals in the UK. While most of this harm is temporary, some of it is serious. The UKPTT offers organisations the means to measure and examine the AEs occurring in their hospital in order to reduce harm.

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Section: Discussionsupporting

confidence: 76%

Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool

et al. 2014

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“…Risk factors for unsafe care in pediatrics are universal, including children's physical characteristics and developmental variability. 27 We hope our results catalyze widespread efforts to improve the safety of pediatric health care in Canada.…”

Section: Resultsmentioning

confidence: 99%

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study

Matlow

Baker

Flintoft

et al. 2012

CMAJ

136

132

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“…Factors related to theoretical vulnerabilities to the occurrence of errors and adverse events, in medical care, in children of all ages, were identified through review of the literature [16]. These factors were then tested to determine the overall extent to which the child-specific factors contributed to the occurrence of the identified patient safety problems and to understand the contribution of each of the specific individual factors to events in all age groups of children.…”

Section: Discussionmentioning

confidence: 99%