[Experiences with "incident reporting" at the East Switzerland Childrens Hospital]. / Erfahrungen mit "Incident Reporting" am Ostschweizer Kinderspital.

Our healthcare system has become a "high-tech" industry and, as a consequence, incidents are almost "normal" events. It is one of the most important obligations in the quality management to get control of these very dangerous and therefore extremely important problems. The Children's Hospital in St. Gallen (Switzerland) introduced in 1998 a reporting system in order to monitor incidents and mistakes and to be able to introduce preventive action. For this we have been using the so called "system approach", i.e. we are not trying to find a guilty person or a single source for a mistake, but we analyze the complete working system involved in the action. According to our experience, such reporting systems have to respect a number of specific rules and prerequisites in order to be successful. The most crucial one is a "change of culture", which means, that we are not looking for a guilty person, but for the weak elements which are responsible for the mistakes in our working systems. In Switzerland a National Foundation for Patient Safety has been created for supporting all the acting professionals in the healthcare system in their challenging task.

Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach.

OBJECTIVE: To examine the occurrence of critical incidents (CIs) in order to improve quality of care. DESIGN: Prospective survey. SETTING: Multidisciplinary, neonatal-pediatric intensive care unit (ICU) of a non-university, teaching children's hospital. PATIENTS: Four hundred and sixty-seven admissions over a 1-year period. METHODS: A CI is any event which could have reduced, or did reduce, the safety margin for the patient. Comprehensive, anonymous, non-punitive CI monitoring was undertaken. CI severity with respect to actual patient harm was graded: major (score 3), moderate (2) or minor (1). The system approach incorporates the philosophy that errors are evidence of deficiencies in systems, not in people. We undertook 2-monthly analyses of CIs. RESULTS: There were 211 CI reports: 30 % major, 25 % moderate, 45 % minor. The CI categories were management/environment 29 %, drugs 29 %, procedures 18 %, respiration 14 %, equipment dysfunction 7 %, nosocomial infections 3 %. The respiratory CIs were the most severe, the drug-related CIs the least severe (score mean, SD: 2.9, 0.26 vs 1.4, 0.76; p < 0.001). However, 20 out of 62 drug-related CIs were potentially life-threatening. Thirteen percent of drug CIs were decimal point errors. Eleven of the 29 respiratory CIs were accidental extubations (2.6/100 ventilator days). CIs were most often precipitated by consultants (32 %), followed by residents (23 %, over-represented in drug CIs, 22/62) and specialized nurses (21 %). Doctors had a greater proportion of major CIs than nurses (p < 0.01). Fifty percent of the CIs were detected by routine checks. The most important method of detection was patient inspection (44 %), alarms accounted for only 10 %. Contributing factors were human errors (63 %), communication failure (14 %), organizational problems (10 %), equipment dysfunction (7 %) and milieu (3 %). CONCLUSIONS: CIs are very common in pediatric intensive care. Knowledge of them is a precious source for quality improvement through changes in the system.

Toxic methaemoglobin concentrations in premature infants after application of a prilocaine-containing cream and peridural prilocaine.

UNLABELLED: We report on a retrospective analysis of eight episodes of toxic methaemoglobinaemia in seven premature infants after the combined exposure to prilocaine by EMLA cream (12.5 mg prilocaine) and caudal anaesthesia (5.4-6.7 mg/kg prilocaine). The causative relationship between prilocaine and the infants' deterioration came to our attention through an anonymous voluntary incident-reporting system. The highest methaemoglobin concentration found was 30.6% (5.5 h after anaesthesia). All infants were symptomatic (mottled skin, paleness, cyanosis, poor peripheral perfusion) and two were exposed to unnecessary diagnostic and therapeutic procedures for unspecified deterioration in their conditions. Pharmacokinetic evaluation indicated a single compartment first-order elimination with a methaemoglobin half-life of 8 h. Normal levels (<1%) were reached 36 h after exposure to prilocaine. CONCLUSION: Whereas local skin application of prilocaine to premature babies is safe, peridural administration is not because premature infants are more sensitive to methaemoglobin inducing agents and tolerate methaemoglobinaemia less well.

Recurrent mediastinal mass in a child with Hodgkin's disease following successful therapy: a diagnostic challenge.

The case of an 11-year-old girl with mediastinal stage III B-E Hodgkin's disease is described. She achieved complete remission with combined chemoradiotherapy according to the Swiss Pediatric Oncology Group-HD Protocol 1985. Six months after all therapy was stopped, a slowly growing retrosternal mass was detected. Computed tomography (CT) and gallium-67 single-photon emission CT (SPECT) could not elucidate the true origin of the tumor, nor did ultrasound-guided transthoracic fine-needle puncture. Open biopsy with histologic examination of the lesion has successfully identified the mass as thymic hyperplasia, a rebound immunologic reaction after chemoradiotherapy that mimicked tumor regrowth.

[Experiences with the early treatment of osteogenesis imperfecta]. / Erfahrungen mit der Frühbehandlung der Osteogenesis imperfecta (OI).

Between 1973 and 1988 twenty children with osteogenesis imperfecta were treated in the Department of Paediatric Surgery at the University of Berne, Switzerland. Our initial experience with the first 15 children, who had virtually no treatment during infancy and early childhood showed that they later developed severe soft tissue and skeletal deformities. Since resulting contractures and curvatures of the long bones are difficult to correct, we changed our therapeutic approach. Traditional therapy in OI was limited to the correction of bony malformations. Considering the fact, that the different elements of the locomotor system are part of a functional entity, we began early treatment combining physiotherapy and surgery.

The effect of biliary enteroenterostomy on the pharmacokinetics of enterally administered cyclosporine in rats.

A major factor in poor bioavailability of cyclosporine in children undergoing orthotopic liver transplantation appears to be poor absorption of the drug. Our hypothesis is that the Roux-en-Y choledochojejunostomy used for biliary drainage in these children causes cyclosporine malabsorption by reducing the length of bowel available for absorption and by distally displacing the entry of bile into the intestine. In these experiments, we determined the effect of biliary enteroenterostomy on the pharmacokinetics of enterally administered cyclosporine in Sprague-Dawley rats. Experimental rats (n = 24) were prepared for study by constructing self-emptying jejunal blind loops. Sham rats (n = 9) had jejunal transection and reanastomosis. Control rats (n = 26) had no operation. Two to 4 weeks later, chronic biliary-enteric fistulae were formed in all animals. In experiments, [3H]cyclosporine was delivered into the duodenum while the site of bile delivery varied. Hourly and cumulative [3H]cyclosporine excretion into bile was quantitated, which our preliminary data show to be a valid estimate of absorption. In control rats, bile was delivered into the duodenum or was replaced with saline and sucrose solution. In experimental rats, bile was infused either into the duodenum, which tested bowel shortening only, or into the proximal end of the blind loop, which tested the combined effects of bowel shortening and distal displacement of bile entry. In sham rats, bile was infused into the duodenum, which controlled for previous abdominal surgery, or into the midjejunum, which tested for distal bile entry only. Two effects of biliary enteroenterostomy on cyclosporine absorption were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary calculi in association with glomerular immaturity.

The syndrome of glomerular immaturity associated with renal tubular acidosis and nephrocalcinosis or urolithiasis is illustrated by a case in which the diagnosis was made before the histological confirmation. Cases of urolithiasis in infants may be associated with this syndrome and attention must be paid to this rare but severe condition.

Blunt liver trauma in children: the role of computed tomography in diagnosis and treatment.

In a retrospective evaluation of 12 children with blunt liver trauma studied by computed tomography (CT), all patients studied preoperatively had subcapsular hematomas (6/6). Eleven of twelve patients had parenchymal lesions that were located predominantly in the superior subsegments of the right lobe: 9/12 posteriorly (segment no. 7) and 7/12 anteriorly (segment no. 8) where transections were most frequent. Lacerations were accompanied by intraparenchymal hematomas. Intravenous bolus contrast enhancement visualizes segmental anatomy and is absolutely necessary in order to map lacerations, recognize nonviable tissue, and relate them to major vessels. Except in critically unstable patients, noninvasive imaging of hepatic and other combined abdominal lesions can avoid diagnostic laparotomy or justify planning of a tailored, maybe less radical surgical procedure. Complications, such as abscess formation, can be demonstrated and drained percutaneously. Despite cost, CT is currently the single best imaging method in acute liver trauma.

The research program and priorities of the Robert Wood Johnson Foundation.

Since its establishment as a national philanthropy in 1972, The Robert Wood Johnson Foundation has appropriated almost $560 million in grants directed toward improvement of health in the United States. Grants are made primarily to develop innovative methods of providing health services, for research and evaluation, and for education and training of health professionals. Since 1972, more than $100 million has been appropriated for research and evaluation projects. The research supported by the Foundation is applied rather than basic, and, like all of the Foundation's programs, must be responsive to the institution's mission. In the 1980s, this mission comprises three objectives: improving access to health care for the most vulnerable underserved population groups, containing increases in health care costs, and improving functional outcomes for patients. In this article, we provide details on the Foundation's research program and priorities, including evolution of the mission, the role of research in the Foundation's overall programs, the purposes for which the Foundation supports research and evaluation activities, and the types of grants available for health services researchers.

Changes in primary medical care delivery, 1975-1979: findings from the physician capacity utilization surveys.

Data from two national telephone surveys of office-based primary care physicians are used to examine changes in patterns of care delivery between 1975 and 1979 in metropolitan and nonmetropolitan areas. Aspects of care delivery considered include physician availability, average physician workload, qualitative attributes of the care delivered, physicians' policies toward acceptance of new patients and fees. Physician availability relative to population increased in metropolitan areas but was unchanged in nonmetropolitan areas. The average number of office visits provided per week declined for physicians in all areas, offsetting to some extent the increase in physician availability; average weekly office visit rates declined most in nonmetropolitan areas. Most of the indicators of the qualitative attributes of care examined suggest that access to primary care physicians increased in both metropolitan and nonmetropolitan areas, though not substantially. Fees increased in real terms in all areas. Relatively fewer physicians were refusing to accept new patients in 1979 than in 1975. The possibility that specialists are providing more primary care in nonmetropolitan areas is considered as a possible explanation for the improvement in qualitative attributes of care delivered by primary care physicians in nonmetropolitan areas despite the decline in per capita office visits provided by primary care physicians in those areas.

[Kidney transplantation in childhood: 10 years' experience]. / Nierentransplantation im Kindesalter: Bilanz nach 10 Jahren.

We report our experiences with 35 renal transplantations in 31 patients in childhood and adolescence. Kidneys were obtained exclusively from deceased donors. At the present time 23 patients are still alive, 19 with a functioning graft whereas 4 are again on haemodialysis. Three-year patient survival rates are 80% and three-year graft survival 62%. Chronic rejection was the main reason for loss of graft or graft function in 14 of 19 patients. Our experiences confirm that renal transplantation is the optimal available therapy for terminal renal insufficiency in childhood.

[Phenylhydrargyrum boricum in glycerin (Glycero-Merfen) in young children: undesirable mercury resorption in mouth mucosa even when free of lesions]. / Phenylmercuriborat in Glycerin (Glycero-Merfen) im Kleinkindesalter: unerwünschte Quecksilberresorption auch bei intakter Mundschleimhaut.

The formulation of phenylhydrargyrum boricum in glycerine (Glycero-Merfen) being frequently used in infants and young children, attention is drawn to the potentially symptomatic mercury absorption associated with its topical administration in that age group. This finding applies to both inflamed and normal oral mucosa. The use of this drug formulation in pediatric patients should be avoided.