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Updated: Jul 15, 2026
A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn
Published on: April 7, 2023
Preventable harm occurring to critically ill children
Gitte Y Larsen1, Amy E Donaldson, Howard B Parker
1Primary Children's Medical Center, Salt Lake City, UT, USA. gitte.larsen@hsc.utah.edu
Insights
Preventable adverse events are common in pediatric intensive care units (PICUs), though serious harm is rare. Younger patients, longer stays, and higher illness burdens increase risk. Focusing on high-risk conditions improves patient safety.
Area of Science:
- Pediatric Critical Care Medicine
- Patient Safety Research
- Healthcare Quality Improvement
Background:
- Adverse events (AEs) in pediatric intensive care units (PICUs) pose significant risks to critically ill children.
- Identifying and characterizing AEs and preventable AEs (PAEs) is crucial for improving patient outcomes.
- Understanding patient factors associated with PAEs can inform targeted prevention strategies.
Purpose of the Study:
- To develop a trigger tool for identifying AEs in critically ill pediatric patients.
- To identify and characterize AEs and PAEs in this population.
- To characterize patients who experience PAEs.
Main Methods:
- Retrospective chart review utilizing a developed trigger tool.
- Systematic sampling of 259 patients from a tertiary, university-affiliated pediatric hospital's PICU over one year.
- Data collection focused on AE occurrence, severity, type, and patient characteristics.
Main Results:
- The frequency of PAEs was 0.19 per patient-day, with 78% minor, 19% moderate, and 3% serious harm.
- Common AE types included sedation (22%), skin (16%), medical device complications (14%), pulmonary (13%), and cardiovascular (11%).
- PAEs were more frequent in younger patients with longer lengths of stay, higher illness burdens, and among surgical patients.
Conclusions:
- PAEs occur frequently in the PICU, but severe harm is uncommon.
- Increased risk for PAEs is associated with the need for sedation, immobility, and vascular/ventilatory devices.
- Targeted prevention strategies focusing on monitoring high-risk conditions and early intervention are more effective than general error prevention.
Objective:
To develop a trigger tool for identifying adverse events occurring in critically ill pediatric patients; to identify and characterize adverse events and preventable adverse events experienced by critically ill pediatric patients; and to characterize the patients who experience preventable adverse events.
Design:
Retrospective chart review using a trigger tool.
Setting:
Pediatric intensive care unit of a tertiary, university-affiliated pediatric hospital.
Patients:
A systematic sample of 259 pediatric intensive care unit patients from a 1-yr period.
Interventions:
None.
Measurements And Main Results:
We measured frequency of occurrence (0.19 preventable adverse events per patient-day), severity of harm (78% minor, 19% moderate, 3% serious, no deaths), and type of event (sedation, 22%; skin, 16%; medical device complication, 14%; pulmonary, 13%; and cardiovascular, 11%). Patients who experienced preventable adverse events were younger, had longer lengths of stay, and had higher illness burdens. Preventable adverse events occurred more frequently among surgical patients than medical patients.
Conclusions:
Preventable adverse events occurred fairly frequently in the pediatric intensive care unit, but serious harm was rare. Conditions that increased the likelihood of a preventable adverse event were a) need for sedation or pain control; b) relative immobility; and c) need for vascular devices, feeding tubes, or ventilators. Adverse event prevention strategies that focus on improving patient monitoring under increased-risk conditions and improving early detection and treatment of potential harm will likely be more effective than strategies aimed at general error prevention.
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