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Measuring Harm in Hospitalized Children via a Trigger Tool
Lya M Stroupe1, Kamakshya P Patra2, Zheng Dai3
1WVU Medicine Children's Hospital, Morgantown, United States.
Insights
The Global Assessment of Pediatric Patient Safety (GAPPS) tool identified four times more adverse events in hospitalized children than the hospital incident reporting system. This tool enhances patient safety by improving the detection of medical errors.
Area of Science:
- Pediatric Patient Safety
- Healthcare Quality Improvement
- Medical Error Detection
Background:
- Medical errors cause significant annual deaths in US hospitals, with existing detection methods being inconsistent.
- Hospitalized pediatric patients face a high risk of adverse events, ranging from 1% to 11% of admissions.
Purpose of the Study:
- To evaluate the Global Assessment of Pediatric Patient Safety (GAPPS) tool for detecting adverse events in a pediatric inpatient setting.
- To compare the efficacy of the GAPPS tool against internal incident reporting systems.
Main Methods:
- A retrospective chart review of 100 pediatric patients was conducted using the GAPPS tool by nurse reviewers.
- Adverse events detected by GAPPS were validated by physicians, who also assessed harm severity and preventability.
- The number of adverse events identified by GAPPS was compared to the hospital's internal incident reports.
Main Results:
- The GAPPS tool detected 20 adverse events in 100 reviewed charts, a detection rate of 4.87% per 411 patient-days.
- The hospital's internal incident reporting system captured only 1.22% of adverse events during the same period.
Conclusions:
- The GAPPS tool is significantly more effective, detecting four times as many adverse events as the current hospital incident reporting system.
- Implementing the GAPPS tool in pediatric hospitals can substantially improve the identification of adverse events and patient harm.
- Findings suggest broader applicability of the GAPPS tool in enhancing patient safety across children's hospitals.
Background:
The 1999 report To Err Is Human published by the Institute of Medicine estimated that between 44,000 and 98,000 deaths occur each year in US hospitals due to medical errors. However, processes to detect medically induced harm remain inaccurate and inconsistent. Hospitalized pediatric patients are at high risk for adverse events, with published rates ranging between 1% and 11% of all hospitalizations.
Objective:
The study aimed to use the Global Assessment of Pediatric Patient Safety (GAPPS) tool to detect adverse events in a pediatric inpatient setting of an academic medical center children's hospital and compare to internal incident reporting methods.
Methods:
Nurse reviewers used the GAPPS tool during a retrospective chart review of 100 patients discharged from the children's hospital. Among the total 100 cases, 20 adverse events were discovered with the tool. Adverse events were validated by physician reviewers, and the severity of harm and preventability were assigned. The number of adverse events was then compared to internal incident reporting for the same time frame.
Results:
The detection rate is 4.87% within 411 patient-days. In contrast, the hospital had only 1.22% incident reports.
Conclusions:
The GAPPS tool can detect four times more adverse events than the hospital incident reporting system. The results are likely to be replicated for other children's hospitals to increase identification of adverse events and harm to patients.
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