Variability in Serious Safety Event Classification among Children's Hospitals: A Measure for Comparison?

Introduction: Hospitals have no standard for measuring comparative rates of serious safety events (SSE). A pediatric hospital safety collaborative has used a common definition and measurement system to classify SSE and calculate a serious safety event rate. An opportunity exists to evaluate the use of this measurement system. Methods: A web-based survey utilizing 7 case vignettes was sent to 132 network hospitals to assess agreement in classifying the vignettes as SSEs. Respondents classified the vignettes according to the taxonomy used at their respective organizations for deviations and SSE classification. Results: Of the 82 respondents, 67 (82%) utilized the same SSE classification system. Respondents did not assess deviations for 2 of the 7 vignettes, which had clear deviations. Of the remaining 5 vignettes, 3 had a substantial agreement of deviation (>85%, Gwet's AC ≥ 0.68), and 2 had fair agreement (<70%, Gwet's AC ≤ 0.39). Four of the 7 vignettes had a substantial agreement on SSE classification (>80%; Gwet's AC ≥ 0.80), and 3 had slight to moderate agreement (<70%, Gwet's AC ≤ 0.78). Conclusions: Results demonstrated agreement and variability in determining deviation and SSE classification in the 7 vignettes. Although the SSE methodology and metric used by participant pediatric hospitals yields generally similar review results, one must be cautious in using the SSE rate to compare patient safety outcomes across different hospitals.

Effect of provider-selected order indications on appropriateness of antimicrobial orders in a pediatric hospital.

PURPOSE: The effect of mandatory provider-selected order indications (PSOIs) on appropriateness of antimicrobial ordering in a tertiary pediatric hospital was evaluated. METHODS: Mandatory PSOIs for 14 antimicrobials were implemented in September 2013. Data on initial and final orders in the first 24 hours after ordering were collected from the electronic medical record. Orders from pre-PSOI and post-PSOI implementation were randomly selected and compared with documentation at the time of order to elicit the documentation-determined clinical indication (DDCI). Appropriateness of the order for the DDCI was evaluated and compared between groups using 2-sample t tests, chi-square tests, and logistic regression. RESULTS: Among the total 1,304 orders included in the review, 275 (21.1%) were inappropriate based on DDCI. The indications associated with the greatest number of inappropriate orders in both groups were suspected sepsis/bacteremia, meningitis/central nervous system infection, and pneumonia. A total of 128 (18.3%) of 700 initial orders were inappropriate compared with the DDCI in the pre-PSOI period, and 82 (17.8%) of 461 initial orders were inappropriate in the post-PSOI period (p = 0.83). A total of 78 (11.1%) of 700 final orders were inappropriate in the pre-PSOI period, and 29 (6.3%) of 461 final orders were inappropriate in the post-intervention period (p = 0.01). Overall, 84 (12%) of 700 inappropriate orders reached the patient in the pre-PSOI period versus 43 (9.3%) of 461 inappropriate orders in the post-PSOI period (p = 0.15). CONCLUSION: PSOIs were effective in reducing inappropriate antimicrobial orders in the first 24 hours after ordering if the correct indication was selected.

Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children.

OBJECTIVE: Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital. METHODS: Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines. RESULTS: After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days. CONCLUSIONS: Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved.

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

OBJECTIVES: Adverse drug events (ADEs) occur more frequently in pediatric patients than adults. ADEs frequently cause serious harm to children and increase the cost of care. The purpose of this study was to decrease ADEs by targeting the entire medication-delivery system for all high-risk medications. METHODS: Thirteen freestanding children's hospitals participated in this ADE collaborative. An advisory panel developed a change package of interventions that consisted of standardization of medication-ordering (eg, consensus-based protocols and order sets and high-alert medication protocols), reliable medication-dispensing processes (eg, automated dispensing cabinets and redesign of floor stock procedures), reliable medication-administration processes (eg, safe pump use and reducing interruptions), improvement of patient safety culture (eg, safety-culture changes and reduction of staff intimidation), and clinical decision support (eg, increase ADE detection and redesign care systems). ADE rates were compared from the 3-month baseline period to quarters of the 12-month intervention phase. ADE rates were categorized further as opioid related and other medication related. RESULTS: From baseline to the final quarter, the collaborative resulted in a 42% decrease in total ADEs, a 51% decrease in opioid-related ADEs, and a 41% decrease in other medication ADEs. CONCLUSION: A pediatric collaborative that targeted the medication-delivery system decreased the rate of ADEs at participating institutions.