How to avoid paediatric medication errors: a user's guide to the literature.

The National Health Service, in its report An organisation with memory, has called for a fundamental rethinking of the way the healthcare system learns from error. The NHS further details its goal to reduce serious medication errors by 40% in a second report entitled Building a safer NHS: improving medication safety. This report calls for a review of paediatric medication delivery systems to assess safety for children.

Physicians' diagnostic judgments and treatment decisions for acute otitis media in children.

Physicians' diagnoses of acute otitis media (AOM) and their treatment choices were investigated using judgment and decision-making analyses. Thirty-two pediatricians in the Albany, New York, area provided probability judgments of the presence of AOM and made treatment decisions for 32 patient vignettes, each described in terms of historical and examination variables. Their probability judgments were well predicted by linear combinations of the patient variables (R2s ranged from 0.76 to 0.97). Information about the observed condition of the eardrum proved to be most critical to the physicians' diagnoses. They demonstrated good levels of agreement on diagnoses. They varied, however, in their tendencies to treat with amoxicillin rather than another antibiotic. Case vagueness was related to the rate of antibiotic treatment. The rate of antibiotic treatment was higher for vague than for non-vague cases when the mean judged probability of AOM was low. In combination, the findings highlight the importance of performing and interpreting ear examinations and the role that consistent training may have in improving management of AOM.

Teaching clinical decision-making to pediatric residents in an era of managed care.

The growth of managed care has brought a new focus on physician competency in the appropriate use of resources to help patients. The community of pediatric educators must improve residency curricula and teaching methodologies to ensure that graduates of their programs can effectively and efficiently meet the needs of children and their families. The educational approach in many pediatric residency programs is an implicit apprenticeship model, with which the residents follow the actions of attending physicians with little attention to scrutiny of the clinical evidence for and against diagnostic and treatment strategies. Evidence-based medicine stresses to the trainee the importance of the evaluation of evidence from clinical research and cautions against the use of intuition, unsystematic clinical experience, and untested pathophysiologic reasoning as sufficient for medical decision-making. Managed care also has helped to create a heightened awareness of the need to educate residents to incorporate the preferences of patients and families into diagnostic and treatment decisions. Trainees must know how to balance their duty to maximize the health of populations at the lowest resource use with their duty to each individual patient and family. Changes in the residency curriculum will bring change in educational settings and the structure of rotations. Potential barriers to implementation will include the need for faculty development and financial resources for information technology.

Hospital admissions of children from the emergency department: are decisions regarding children on public assistance different?

OBJECTIVE: To better understand the variables that influence the physician's decision to admit children from the emergency department (ED) for nonmedical problems. METHODS: A multicenter prospective questionnaire survey over a three-month study period. For all admitted children, the emergency physician completed a survey which recorded demographic data, insurance status, primary care provider (PCP), admitting diagnoses, and reason for admission. The reason for admission was noted as strictly medical or nonmedical (either an illness that could have been managed on an ambulatory care basis or a "psychosocial" admission). Group differences were analyzed by t test, chi 2, or logistic regression analysis where appropriate. RESULTS: There were 4318 ED admissions at five institutions of which 185 (4%) were judged to be nonmedical. No age or gender differences were found between the medical and nonmedical admission populations. Using logistic regression, adjusted odds ratios for nonmedical admissions were as follows: Medicaid insurance (2.34, 95% CI = 1.61-3.41), clinic-based primary care provider (1.54, 95% CI = 1.06-2.23), no or unknown primary care provider (2.40, 95% CI = 1.52-3.78), and after hours [eg, 5 PM to 8 AM] admissions (1.86, 95% CI = 1.31-2.63). CONCLUSIONS: These data suggest that children with lower socioeconomic status and limited primary care resources are more likely to be admitted from the ED for nonmedical reasons than children with commercial insurance resources or a private physician.

A community-based survey of infant sleep position. Pediatric Research in Office Practices Network.

OBJECTIVE: To determine prevalent infant sleep positions before and after the American Academy of Pediatrics position statement of 1992 and to identify determinants of sleep position. DESIGN: cross-sectional survey. SETTING: private and hospital-sponsored general pediatric offices. PARTICIPANTS: parents of infants younger than 7 months of age. RESULTS: Eight hundred fifty-two care givers completed surveys during the 5-week study. Fifty-four percent of the study infants were put to sleep in the prone position. In 416 families with more than one child, however, 75% of the youngest siblings had been put to sleep in the prone position at the same age. Gender, race, family income, maternal smoking, and birth weight were not associated with choice of sleep position. CONCLUSIONS: There has been a change in infant sleep positioning in the desired direction since the American Academy of Pediatrics statement. However, 54% of the study infants were still being put to sleep prone.

Attention deficit hyperactivity disorder, creativity, and the effects of methylphenidate.

Given that children with attention deficit hyperactivity disorder (ADHD) are more impulsive than peers, this study explored whether they are correspondingly more creative, and whether creativity declines when impulsivity is decreased through methylphenidate (Ritalin) therapy. A repeated-measures quasi-experimental design was used to compare the performance of 19 boys with previously diagnosed ADHD and 21 comparison boys aged 8 through 11 on two administrations of alternate forms of the Torrance Tests of Creative Thinking-Figural (nonverbal). Boys with ADHD received prescribed methylphenidate only for the first session. Overall, mean Torrance summary scores for comparison boys (mean = 115.1, SD = 16.1) were higher than for boys with ADHD (mean = 107.6, SD = 12.7). However, the difference between means was small (7%) and did not meet the 25% criterion for a clinically significant difference. No changes in performance over time (comparison group) or medication state (ADHD group) were observed. These data suggest that, when measured nonverbally, the creative thinking performance of boys with ADHD is not superior to that of peers who do not have ADHD. Regarding the effects of methylphenidate, prescribed therapy did not influence performance on this measure of creative thinking.

Implementation of COSTAR in an academic group practice of general pediatrics.

High-quality medical care requires a medical record that is complete, legible, and readily available. Information storage and retrieval are often more difficult in academic group practices than in private offices because of the complexity of the delivery system. We implemented a computerized medical record (COSTAR) in our academic group practice in pediatrics, and recorded data on 14,486 visits for preventive health care or illness over an 18-month period. Except when follow-up visits were made within 48 hours of an encounter, a complete medical record was available at all times. The attending staff physicians were enthusiastic about the computer-based record, and after a period of adaptation, the residents were as well. The nurses and clerical staff agreed that it improved office efficiency and thus patient care. Yet the system was abandoned in the face of medical college politics and problems in other practices at our institution.

Circumcision: is the risk of urinary tract infection really the pivotal issue?

Recent information regarding the increased risk of urinary tract infections in the first year of life for uncircumcised boys has created confusion regarding the appropriate guidance to be given to parents confronting the circumcision issue. A decision model was built that addressed the question of whether or not to circumcise a newborn male considering the probability of a non-circumcised boy having a UTI in the first year of life (0.041), the probability of a circumcised boy having a UTI in the first year of life (0.002), and the likelihood of renal scarring from a UTI (0.075). After considering the morbidity associated with the procedure, all possible outcomes were ranked from worst to best (circumcised-renal pathology to uncircumcised-no infection) and given a value on a 0 to 1 scale. For the set of values assigned to the outcomes, the choice of no circumcision yielded the highest expected utility. For the set of assigned utilities, sensitivity analysis showed that unless the probability of a UTI in the first year of life for an uncircumcised male was greater than or equal to 0.29, then non-circumcision was still the preferred choice. The decision was most sensitive to the degree of aversion to the morbidity associated with the procedure (pain, bleeding, inflammation).

Teen Line: a descriptive analysis of a peer telephone listening service.

Teen Line is a peer telephone listening service for adolescents. During its first year of operation, 2,270 phone calls were received. After an initial novelty effect, counts document a consistent level of use of the service. Two-thirds of the callers were female. Although 4% of topics discussed dealt with crisis situations (suicide, physical abuse), 96% were concerned with common, less urgent adolescent issues, such as peer relationships, family dynamics, and the need to have someone "just to talk to." This paper presents a model for an adolescent listening service and provides data garnered over a year's utilization. Consistent use documents its acceptance as a source of information for teenagers.

Compliance with a prescription for psychotherapeutic counseling in childhood.

Pediatricians frequently refer children and their families for psychotherapeutic counseling. In order to maximize compliance with such a prescription, the physician should be aware of factors associated with noncompliance. We conducted a systematic retrospective analysis of factors associated with following a recommendation for counseling. We reviewed the records of 35 children who had been referred for counseling. One to two years after the recommendation was made, we asked their parents whether or not they had accessed these services. Compliant and noncompliant families were compared on a number of demographic, historical, and diagnostic parameters. No statistically significant association with the compliance factor was found. Only 53% of children had received the prescribed therapy. We conclude that noncompliance with a recommendation for psychotherapeutic counseling is a problem of significant proportion. Further work with a larger sample size will be needed to elucidate factors associated with noncompliance.

Multidisciplinary team evaluation of school dysfunction. An analysis of utilization.

Little is known of the characteristics of children experiencing school dysfunction who are evaluated by multidisciplinary teams. The records of 87 children seen during a calendar year were reviewed and information was gathered regarding their age, sex, and referral source. In addition, the chief concerns of the child's parents and educators, and the diagnostic outcome, were considered. Boys were more likely to have been referred for behavioral problems than for academic issues. Girls were seen at an earlier age. Younger children were more likely to have been referred by physicians. While there was a significant association between gender and reason for referral, we found no such relationship between gender and final diagnostic classification. Variables in the utilization of evaluation services are described. Cognizance of these issues should lead to improved provision of care to all children experiencing school dysfunction.

Utilization of emergency services among patients of a pediatric group practice.

Pediatric group practices in university hospitals provide primary care to children who are often from indigent families. Those practices that attempt to provide care in a continuous way often encounter difficulty in attempting to change their patients' patterns of emergency department utilization. This study attempts to define the relationship between patient characteristics such as access to a telephone and inappropriate utilization of the emergency department. A university hospital database was reviewed to identify all patients of the pediatric group practice. Emergency department records over a six-month period were reviewed to identify all visits of group practice patients to the emergency department. Patients without access to a telephone were more likely to inappropriately access care in the emergency department than were patients with phone access. However, within the cohort of emergency department utilizers, phone access was not a predictor of use. Of those who used the emergency department, babies and young children and those of indigent status were more likely to inappropriately access care than were older children and those at a higher socioeconomic level. We conclude that the demographic information of clients in a pediatric group practice can be utilized to predict inappropriate utilization of emergency department services and that this information can be used to implement programs to help foster continuity of care.

Variation in clinical practice in the management of febrile seizures.

Febrile seizures are a common problem facing those who provide health care to children. Wide variation in physician management of the simple febrile seizure has been reported. Recent published data have helped to clarify some of the diagnostic and therapeutic issues confronting the physician managing a child with this entity. In order to assess the current management of the child with a first simple febrile seizure, a questionnaire was sent to 584 physicians who care for children. Twenty-five percent of the respondents reported that they would use anticonvulsant therapy in a manner that has been shown to be ineffective. The responses showed that wide variation still exists in the management of febrile seizures.