Pediatric safety incidents from an intensive care reporting system
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Published on: April 7, 2023
Julia Lynn Skapik1, Peter J Pronovost, Marlene R Miller
1Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
Insights
Pediatric intensive care units (PICUs) frequently see patient harm. Line, tube, and airway events pose the greatest risk, highlighting the need for improved safety protocols and provider training to protect vulnerable children.
Area of Science:
- Pediatric Patient Safety
- Healthcare Quality Improvement
- Intensive Care Medicine
Background:
- Adverse events in healthcare present significant burdens.
- Understanding incidents in pediatric intensive care units (PICUs) is limited.
- This study addresses safety incidents specific to pediatric critical care.
Purpose of the Study:
- To examine demographic factors, event types, system factors, and harm in PICU incidents.
- To identify predictors of harm in pediatric safety events.
- To inform strategies for improving patient safety in PICUs.
Main Methods:
- Cross-sectional analysis of two years of safety incident data.
- Utilized voluntary reports from the Intensive Care Unit Safety Reporting System.
- Included analysis of harm and contributing factors for pediatric safety incidents.
Main Results:
- Two-thirds of 464 reported incidents resulted in patient harm.
- Line, tube, and airway events were associated with greater harm than medication errors.
- Patient-related factors were the strongest predictor of harm, followed by training and education.
Conclusions:
- Pediatric patients experience frequent harm in intensive care settings.
- Safety can be enhanced through protocols for high-risk procedures, improved monitoring, and staff training.
- Identifying at-risk patients allows for proactive safety interventions.
Objectives:
Adverse events impose a great burden on patients and the health care system, but not enough is known about how to address incidents involving pediatric patients. This study examined the demographic factors, types of events, contributing system factors, and harm associated with incidents that occur in pediatric intensive care units.
Methods:
Cross-sectional analysis of 2 years of data on all pediatric safety incidents and near misses reported to the voluntary provider-recorded Intensive Care Unit Safety Reporting System in regards to harm and contributing factors.
Results:
In 464 incidents reported from 23 intensive care units to the Intensive Care Unit Safety Reporting System, patients were physically injured in one third of incidents and harmed in some way in two thirds of incidents. Medication errors were the most common incident type, but were associated with less harm than other event types. Line, tube, and airway events comprised one third of incidents and were associated with more harm than other types. Patient contributing factors were a strong predictor of harm; training and education factors were also commonly cited. In multivariate analysis, patient factors were the strongest predictor of harm adjusting for age, sex, and race.
Conclusions:
Pediatric patients are commonly harmed in intensive care units. There are several potential ways to improve safety including protocols for high-risk procedures involving lines and tubes, improved monitoring, and staffing, training and communication initiatives. Providers may be able to identify patients at increased risk for harm and intervene to protect patient safety.
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