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The Pediatric Index of Mortality as a Trigger Tool for the Detection of Serious Errors and Adverse Events
Christoph M Rüegger1,2, Bernhard Frey1
1Department of Intensive Care and Neonatology, University Children's Hospital Zürich, Switzerland.
Insights
Patients who die in pediatric intensive care units (PICU) despite low predicted mortality may experience serious safety events. Routine review of these cases can identify system improvements for better patient care.
Area of Science:
- Pediatric critical care medicine
- Patient safety research
- Healthcare quality improvement
Background:
- Predictive mortality scores in pediatric intensive care units (PICUs) help assess patient risk.
- Identifying factors contributing to unexpected deaths in low-risk PICU patients is crucial for improving care.
Purpose of the Study:
- To investigate the hypothesis that pediatric patients who die in the PICU with a low predicted mortality have experienced serious errors and adverse events.
- To compare the incidence of safety-related events between low-risk PICU patients who died and those who survived.
Main Methods:
- Retrospective cross-sectional review of medical records for serious errors and adverse events.
- Analysis of 72 deaths in PICU patients with a Pediatric Index of Mortality (PIM) < 10% (trigger-positive) compared to 100 survivors with PIM < 10% (trigger-negative).
Main Results:
- Forty-five serious errors and adverse events were identified: 0.47 per trigger-positive admission vs. 0.11 per trigger-negative admission (p < 0.001).
- Clinical sepsis acquired during PICU stay was linked to 42% of events (89% in trigger-positive cases).
- Medication-related events occurred in 18% of cases, exclusively in trigger-positive admissions (p = 0.001).
Conclusions:
- PICU patients who die unexpectedly despite low predicted mortality are more likely to have experienced serious safety-related events.
- Routine medical record review and morbidity and mortality conferences for these cases can identify system vulnerabilities.
- Addressing these adverse events through system changes can enhance patient safety and care quality in PICUs.
Objectives:
To test the hypothesis that patients who die in a PICU despite a low predicted mortality at PICU admission are affected by serious errors and adverse events.
Design:
Retrospective cross-sectional review of medical records for serious errors and adverse events.
Setting:
Tertiary interdisciplinary neonatal PICU.
Patients:
All admissions to our PICU who died despite a low expected mortality (Pediatric Index of Mortality) of less than 10% (trigger-positive admissions). They were compared with a random sample of 100 PICU admissions with a Pediatric Index of Mortality of less than 10% who survived (trigger-negative admissions).
Interventions:
None.
Measurements And Main Results:
There were 7,383 admissions (91%) with a Pediatric Index of Mortality 2 below 10%. Seventy-two trigger-positive admissions and 100 trigger-negative admissions met the criteria for detailed chart review. Forty-five serious errors and adverse events were identified, 0.47 per trigger-positive admission and 0.11 per trigger-negative admission (p < 0.001). Nineteen serious errors and adverse events (42%) were related to clinical sepsis acquired during the PICU stay, 17 (89%) in trigger-positive admissions and two (11%) in trigger-negative admissions (p < 0.001). A further 18 serious errors and adverse events (40%) were intervention related, nine (50%) in trigger-positive admissions and nine (50%) in trigger-negative admissions (p = 0.46). Eight serious errors and adverse events (18%) were associated with medication use, all of which occurred in trigger-positive admissions (p = 0.001). The median (interquartile range) age for admissions with and without serious errors and adverse events was 0.3 months (0.0-4.6 mo) and 7.4 months (0.4-58.4 mo) (p < 0.001), and their median (interquartile range) duration of invasive ventilation was 140 hours (50-451 hr) and 2 hours (0-41 hr) (p < 0.001), respectively.
Conclusions:
The records of PICU patients with a low expected mortality at admission and death in PICU should be reviewed routinely and/or discussed at morbidity and mortality meetings. These patients may have experienced more in-hospital safety-related events compared with PICU patients with a low Pediatric Index of Mortality who survived. Such adverse events may be amenable to system changes, thus improving patient care.
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