Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study

Area of Science:

• Pediatric Critical Care Medicine
• Patient Safety Research
• Healthcare Quality Improvement

Background:

• Critically ill children dying in paediatric intensive care units (PICUs) often experience adverse events during pre-hospital and hospital management.
• Understanding these patient safety factors is crucial for improving outcomes in pediatric critical care.

Purpose of the Study:

• To identify patient safety factors in the pre-hospital and hospital management of critically ill children who died in a PICU.
• To analyze adverse events contributing to death (AEds) and critical incidents (CIs) in this vulnerable population.

Main Methods:

• Retrospective review of case notes from a single tertiary regional PICU in London.
• Analysis of 47 patient deaths (7% of admissions) over two years (2007-2008).
• Defined and categorized adverse events contributing to death (AEds) and critical incidents (CIs).

Main Results:

• 36% of cases had AEds, predominantly related to diagnosis and management of critical illness in pre-PICU hospital care.
• 60% of cases had CIs, occurring across the entire patient journey (pre-hospital, pre-PICU, transport, and PICU).
• Individual, team, and organizational factors were identified as major contributors to both AEds and CIs.

Conclusions:

• Adverse events during pre-PICU hospital care are common and significantly impact outcomes for children who die in the PICU.
• Critical incidents are pervasive throughout the patient's journey, emphasizing systemic issues in care delivery.
• Further interventional studies are essential to develop and implement effective strategies for enhancing patient safety in pediatric critical care.