Using a Pediatric Trigger Tool to Estimate Total Harm Burden Hospital-acquired Conditions Represent.

INTRODUCTION: To improve patient safety, the Centers for Medicare & Medicaid Services (CMS) has promoted systematically measuring and reporting harm due to patient care. The CMS's Partnership for Patients program identified 9 hospital-acquired conditions (HACs) for reduction, to make care safer, more reliable, and less costly. However, the proportion of inpatient pediatric harm represented by these HACs is unknown. METHODS: We conducted a retrospective review of 240 harms previously identified using the Pediatric All-Cause Harm Measurement Tool, a trigger tool that is applied to medical records to comprehensively identify harms. The original sample included 600 randomly selected patients from 6 children's hospitals in February 2012. Patients with rehabilitation, obstetric, newborn nursery, and psychiatric admissions were excluded. The 240 identified harms were classified as a HAC if the event description potentially met the definition of 1 of the 9 CMS-defined HACs. HAC assessment was performed independently by 2 coauthors and compared using Cohen's Kappa. RESULTS: Two hundred forty harms across 6 children's hospitals were identified in February 2012 using a pediatric global trigger tool. Agreement between the coauthors on HAC classification was high (Kappa = 0.77). After reconciling differences, of the 240 identified harms, 58 (24.2%; 95% confidence interval: 9.1-31.7%) were classified as a CMS-defined HAC. CONCLUSIONS: One-fourth of all harms detected by a pediatric-specific trigger tool are represented by HACs. Although substantial effort is focused on identifying and minimizing HACs, to better understand and ultimately mitigate harm, more comprehensive harm identification and quantification may be needed to address events unidentified using this approach.

Development of an Electronic Pediatric All-Cause Harm Measurement Tool Using a Modified Delphi Method.

OBJECTIVES: To have impact on reducing harm in pediatric inpatients, an efficient and reliable process for harm detection is needed. This work describes the first step toward the development of a pediatric all-cause harm measurement tool by recognized experts in the field. METHODS: An international group of leaders in pediatric patient safety and informatics were charged with developing a comprehensive pediatric inpatient all-cause harm measurement tool using a modified Delphi technique. The process was conducted in 5 distinct steps: (1) literature review of triggers (elements from a medical record that assist in identifying patient harm) for inclusion; (2) translation of triggers to likely associated harm, improving the ability for expert prioritization; (3) 2 applications of a modified Delphi selection approach with consensus criteria using severity and frequency of harm as well as detectability of the associated trigger as criteria to rate each trigger and associated harm; (4) developing specific trigger logic and relevant values when applicable; and (5) final vetting of the entire trigger list for pilot testing. RESULTS: Literature and expert panel review identified 108 triggers and associated harms suitable for consideration (steps 1 and 2). This list was pared to 64 triggers and their associated harms after the first of the 2 independent expert reviews. The second independent expert review led to further refinement of the trigger package, resulting in 46 items for inclusion (step 3). Adding in specific trigger logic expanded the list. Final review and voting resulted in a list of 51 triggers (steps 4 and 5). CONCLUSIONS: Application of a modified Delphi method on an expert-constructed list of 108 triggers, focusing on severity and frequency of harms as well as detectability of triggers in an electronic medical record, resulted in a final list of 51 pediatric triggers. Pilot testing this list of pediatric triggers to identify all-cause harm for pediatric inpatients is the next step to establish the appropriateness of each trigger for inclusion in a global pediatric safety measurement tool.

A trigger tool to detect harm in pediatric inpatient settings.

OBJECTIVES: An efficient and reliable process for measuring harm due to medical care is needed to advance pediatric patient safety. Several pediatric studies have assessed the use of trigger tools in varying inpatient environments. Using the Institute for Healthcare Improvement's adult-focused Global Trigger Tool as a model, we developed and pilot tested a trigger tool that would identify the most common causes of harm in pediatric inpatient environments. METHODS: After formal training, 6 academic children's hospitals used this novel pediatric trigger tool to review 100 randomly selected inpatient records per site from patients discharged during the month of February 2012. RESULTS: From the 600 patient charts evaluated, 240 harmful events ("harms") were identified, resulting in a rate of 40 harms per 100 patients admitted and 54.9 harms per 1000 patient days across the 6 hospitals. At least 1 harm was identified in 146 patients (24.3% of patients). Of the 240 total events, 108 (45.0%) were assessed to have been potentially or definitely preventable. The most common patient harms were intravenous catheter infiltrations/burns, respiratory distress, constipation, pain, and surgical complications. CONCLUSIONS: Consistent with earlier rates of all-cause harm in adult hospitals, harm occurs at high rates in hospitalized children. Availability and use of an all-cause harm identification tool will establish the epidemiology of harm and will provide a consistent approach to assessing the effect of interventions on harms in hospitalized children.

Prevalence of adverse events in pediatric intensive care units in the United States.

OBJECTIVES: Selection of relevant patient safety interventions for the pediatric intensive care (PICU) requires identification of the types and severity of adverse events (AEs) and adverse drug events (ADEs) that occur in this setting. The study's objectives were to: 1) determine the rates of AEs/ADEs, including types, severity, and preventability, in PICU patients; 2) identify population characteristics associated with increased risk of AEs/ADEs; 3) develop and test a PICU specific trigger tool to facilitate identification of AEs/ADEs. DESIGN, SETTING, PATIENTS: Retrospective, cross-sectional, randomized review of 734 patient records who were discharged from 15 U.S. PICUs between September and December 2005. INTERVENTION: A novel PICU-focused trigger tool for AE/ADE detection. MEASUREMENTS AND RESULTS: Sixty-two percent of PICU patients had at least one AE. A total of 1488 AEs, including 256 ADEs, were identified. This translates to a rate of 28.6 AEs and 4.9 ADEs per 100 patient-days. The most common types of AEs were catheter complications, uncontrolled pain, and endotracheal tube malposition. Ten percent of AEs were classified as life-threatening or permanent; 45% were deemed preventable. Higher adjusted rates of AEs were found in surgical patients (p = .02), patients intubated at some point during their PICU stay (p = .002), and patients who died (p < .001). Surgical patients had higher preventable adjusted AE (p = .01) and ADE rates (p = .02). The adjusted cumulative risk of an AE per PICU day was 5.3% and 1.6% for an ADE alone. There was a 4% increase in adjusted ADEs rates for every year increase in age. CONCLUSIONS: AEs and ADEs occur frequently in the PICU setting. These data provide areas of focus for evidence-based prevention strategies to decrease the substantial risk to this vulnerable pediatric population.

Closing the gap in children's quality measures: a collaborative model.

The need for measures of the quality of healthcare provided to children and adolescents is well documented. However, children have been underrepresented in national healthcare quality measurement and reporting efforts. The Pediatric Data Quality Systems (Pedi-QS) Collaborative is addressing this gap. Two consensus measure sets and an assessment of nursing-sensitive indicators in pediatric care have been produced through the collaborative. The framework and measure set development process are described. Lessons learned from applying the process are summarized, and future directions are suggested. Voluntary collaborative efforts are vital for advancing children's measures, and national support and funding are also needed.

Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs.

OBJECTIVES: Currently there are few practical methods to identify and measure harm to hospitalized children. Patients in NICUs are at high risk and warrant a detailed assessment of harm to guide patient safety efforts. The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool. METHODS: A NICU-focused trigger tool for adverse event detection was developed and tested. Fifty patients from each site with a minimum 2-day NICU stay were randomly selected. All adverse events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger, and the entire tool, was evaluated for positive predictive value. Study chart reviewers, in aggregate, identified 88.0% of all potential triggers and 92.4% of all potential adverse events. RESULTS: Review of 749 randomly selected charts from 15 NICUs revealed 2218 triggers or 2.96 per patient, and 554 unique adverse events or 0.74 per patient. The positive predictive value of the trigger tool was 0.38. Adverse event rates were higher for patients <28 weeks' gestation and <1500 g birth weight. Fifty-six percent of all adverse events were deemed preventable; 16% could have been identified earlier, and 6% could have been mitigated more effectively. Only 8% of adverse events were identified in existing hospital-based occurrence reports. The most common adverse events identified were nosocomial infections, catheter infiltrates, and abnormal cranial imaging. CONCLUSIONS: Adverse event rates in the NICU setting are substantially higher than previously described. Many adverse events resulted in permanent harm and the majority were classified as preventable. Only 8% were identified using traditional voluntary reporting methods. Our NICU-focused trigger tool appears efficient and effective at identifying adverse events.