Measuring Harm in Hospitalized Children via a Trigger Tool.

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.