A tool developed to prevent medical errors (“harms”) in pediatric inpatients found that nearly half of the harms in patient charts were preventable, according to a pilot study to measure the tool’s effectiveness.

In a retrospective review of 600 charts, 240 (45%) contained medical harms assessed as being “potentially or definitely preventable,” reported David C. Stockwell, MD, MBA, of Children’s National Health System in Washington D.C., and colleagues.

This resulted in the rate of 40 harms per 100 patients admitted (95% CI: 35.2-45.4) and 54.9 harms per 1000 patient days (95% CI: 48.3-62.3), they wrote in Pediatrics.

The Pediatric All-Cause Harm Measurement Tool (PACHMT) was designed by the authors to detect triggers – defined as “a medical record based ‘hint’ that ‘triggers’ the search of the medical record to determine whether an adverse event might have occurred.”

During the chart review, the PACMHT identified 85.0% of all harms, and also identified 36 triggers (70.6% of all PACHMT triggers) at least once during the chart review.

Researchers determined that 146 (24.3%) patients experienced ≥1 harm, with 51 (8.5%) experiencing multiple harms. The most common of these were intravenous catheter infiltrations/burns, respiratory distress, constipation, pain, and surgical complications, and 68% of these were rated level E on theNational Coordination Council for Medication Error Reporting and Prevention harm scale.

While the positive predictive value of the aggregate PACHMT trigger list was 22.0% (95% CI: 19.0-25.1), it varied for each individual trigger. Healthcare associated-infections (n=7) had the highest positive predictive value at 85.7% (95% CI: 42.1-99.6). Though elevated pain score (≥6 of 10) was the trigger most frequently noted (n=179), the positive predictive value was only 6.7% (95% CI: 3.5-11.4). Eight triggers had a positive predictive value of 0, though each was observed less than four times during the chart review.

The authors said that 22 (9.2%) of harms were also identified through voluntary reporting. However, they note that only 2% to 8% of harms have been captured through this system even though it is the main method of reporting harms in most hospitals.

The PACHMT was modeled off the Institute of Healthcare Improvement Global Trigger Tool (IHI GHT) used in adult settings. In a separate interview with MedPage Today, Stockwell said that the rate of harms captured by the PACHMT was consistent compared to the rate detected in high-volume tertiary care adult-based institutions.

“Many of us that work in patient safety have the understanding that we don’t measure safety consistently and accurately in most organizations,” he said. “Our focus was to try and build on some work that had been done in adult medicine and try to apply it in pediatrics and then take it to a number of the country’s leading centers to validate that our suspicions were accurate.”

Researchers examined data from six academic children’s hospitals each evaluating 100 charts apiece from patients hospitalized in February 2012. Eligible participants had a length of stay between 24 hours and 6 months, though the median length of stay was 4 days (IQR: 3-7). The sample was 47.8% female (n=287) with a median age of 4 years (IQR: 0.5-12.0), though all patients were <22 years. Reviewers consisted of one nonphysician clinical reviewer (a nurse or pharmacist) and one physician reviewer, who each completed training on how to use the PACHMT through webinars led by IHI GTT experts. They identified 1093 harms total, with a mean chart review time of 42 minutes apiece.

Authors note limitations to their study include its relatively small sample size, and the lack of two physician reviewers. There was also no evidence for which triggers were included in the tool, and not all harms were captured during the review, and no “intrarater reliability testing” to determine if the tool was consistent across reviewers. They recommend larger studies to better identify patient harms, as they comment their study was only a Pilot study.

“Use of such trigger tools will lead to a better understanding of the epidemiology of harm in hospitalized children as well as allow tracking of change with patient-safety-focused interventions,” Stockwell and his colleagues concluded. He said separately that work was already being done with Boston Children’s Hospital to refine the list of triggers in the tool so that it’s easier for hospitals to adopt.

“All healthcare providers really do show up to work every day to take good care of the patients they’re working on and the only way to improve that care is to understand the vulnerabilities that happen,” he said. “I’d certainly like to see more hospitals use an active surveillance approach like the [PACHMT] to understand their safety events more robustly.”

• Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

last updated 05.18.2015