Key points

Introduction

The implementation of quality control within the field of health care has become a matter of extreme importance in a very short period of time. From its initial surge of recognition less than 2 decades ago, standards of quality assurance have proliferated ceaselessly. These have been accompanied closely by intense scrutiny, and for good reason. Estimates of annual deaths due to medical errors have been placed in the hundreds of thousands. Errors in pediatric medicine are especially perturbing. Children are at a much higher risk of experiencing harm when compared with adults, mainly due to weight-based medication requirements, developmental changes, and dependency on caregivers. Yet, pediatric quality measures still lag behind those of adults.

Introduction

The implementation of quality control within the field of health care has become a matter of extreme importance in a very short period of time. From its initial surge of recognition less than 2 decades ago, standards of quality assurance have proliferated ceaselessly. These have been accompanied closely by intense scrutiny, and for good reason. Estimates of annual deaths due to medical errors have been placed in the hundreds of thousands. Errors in pediatric medicine are especially perturbing. Children are at a much higher risk of experiencing harm when compared with adults, mainly due to weight-based medication requirements, developmental changes, and dependency on caregivers. Yet, pediatric quality measures still lag behind those of adults.

The quality assurance movement

Most would accredit the Institute of Medicine for catalyzing the initial spark of interest in health care quality assurance. The organization’s 1999 publication, To Err is Human , addressed the multitude of issues stemming from medical errors. The effects of the study were sudden and drastic, drawing widespread attention to the problem from several directions and even influencing legislative change.

The appeal of reformation is deeply rooted in the prevention of avoidable patient injuries and deaths. Above all, it is these numbers that are and should be the most compelling fragments of data when it comes to the facilitation of quality improvement. However, the implications of a faulty medical system extend into all aspects of society, not the least of which are financial burdens. The study presented figures north of $17 billion in annual expenses as a result of medical errors. The health care system saw a dire decrease in trust, and physicians and patients alike suffered a loss of satisfaction and morale. The movement was, overall, one that would benefit the nation as a whole. In the same year, the Healthcare Research and Quality Act of 1999 was passed, promoting health care quality and improvement.

In Crossing the Quality Chasm , The Institute of Medicine described 6 attributes of quality in health care: safety, effectiveness, patient-family centeredness, timeliness, efficiency, and equity. Several safety and quality efforts as well as hospital strategic plans have been built around those domains since that time. In 2003, The Agency for Healthcare Research and Quality (AHRQ) released a set of patient safety indicators (PSIs), to identify potentially adverse patient care events. After testing and validating the PSIs in adults, AHRQ revised them in 2006 and formulated a pediatric module. Subsequently, The Joint Commission’s National Patient Safety Goals, AHRQ’s PSIs, inpatient quality indicators, and Pediatric Quality Indicators were all released. The American Academy of Pediatrics (AAP) also came out with a statement summarizing information on how to develop and appropriately use quality measures to address issues that are relevant and important in pediatric health care.

In 2012, 6 free-standing children’s hospitals collectively developed a trigger tool using the Institute for Healthcare Improvement’s adult-focused Global Trigger Tool model and pilot tested it to identify the most common causes of harm in pediatric inpatient settings. They found that harm to hospitalized children occurs at high rates, similar to all-cause harm in hospitalized adults.

In 2007, the Centers for Medicare and Medicaid Services (CMS) announced its intent to use quality measures to guide reimbursement to hospitals. More recently, CMS also declared that state Medicaid programs could refuse to reimburse health care organizations for services rendered in treating certain provider-preventable conditions.

Pediatric hospital medicine and inpatient health care

Pediatric hospital medicine (PHM) was formally recognized as a distinct discipline of pediatrics by AAP in 1999 when it approved the inception of Provisional Section on Hospital Care. The term “hospitalist,” which is now a well-recognized designation, was originally coined by Wachter and Goldman in 1996. A pediatric hospitalist is a pediatrician whose primary role is to take care of hospitalized patients and whose responsibilities also include patient care, teaching, mentoring, research, and leadership related to hospital medicine. The guiding principles for PHM programs are well delineated in AAP’s policy statement released in October 2013.

PHM is the fastest growing specialty of pediatrics. Pediatric hospitalists possess the necessary skills to coordinate patient care, integrate hospital systems, and maximize efforts to enhance patient safety and influence positive outcomes in the complex inpatient environment. PHM groups are taking care of more patients, and are in charge of more processes in hospitals. In addition to managing sick children with a multitude of medical and social problems, pediatric hospitalists are also faced with pressures to reduce length of stay, avoid hospital-acquired conditions, and prevent readmissions.

Quantification

The clear first step toward being able to facilitate and track quality improvement lies in the formulation of measurable statistics. To see what is lacking, and thus see where progress can be made, a list of criteria needs to be determined. All gauges of patient safety and health care quality must be quantifiable. By coming to a consensus about these metrics, a systematic change can begin to be implemented, and improvements can be traced with concrete data.

To instigate this process, a strategic planning meeting was held in February of 2009, collectively by the Society of Hospital Medicine, the Section on Hospital Medicine of the AAP, and the Academic Pediatric Association, following which a Pediatric Hospital Medicine Dashboard Committee was formed that put together several consensus metrics and created a dashboard for PHM groups. This proposed dashboard was published in 2010.

The goal of this dashboard was to promote internal and external monitoring and comparison among the various PHM groups, with the expectation that these will provide a starting point for data collection toward improving inpatient pediatric care. Metrics of this dashboard were separated into 6 categories: descriptive data, clinical quality data, nonclinical quality data, productivity measures, resource utilization, and group sustainability. Each category was then divided into 2 groups: “recommended metrics” and “metrics to consider.”

Medication errors in hospitalized children

Safely administering medications to hospitalized children is a complex task and requires several steps to be done correctly, to prevent medication errors. Medication dosing is more complicated in children because of the differences in their weight, body surface area, organ system maturity, and ability to metabolize and excrete drugs. Paucity of standardized dosing regimens for children also makes it more challenging. Additionally, several drugs are being used in children based on very limited evidence, without specific dosing guidelines or pediatric indications or formal approval from a US Food and Drug Administration licensing agency, putting children at increased risk of medication errors.

Administration of medications may be associated with adverse reactions that are mostly unpredictable and nonpreventable, or adverse effects related to the inherent properties of the drug that are predictable but still nonpreventable. “Medication errors,” on the other hand, often occur as a result of human mistakes or system failures and are, for the most part, preventable. An allergic reaction to a medication that happens to a patient with no history of drug allergy is considered an adverse reaction, but if the same reaction happens because of failure to obtain or document drug allergy, then it is considered a medication error. A medication error is defined as any preventable event that occurs during the process of ordering or delivering a medication, regardless of whether an injury occurred or the potential for injury was present.

Errors can occur during medication selection, medication ordering, order transcription, drug formulation, drug dispensing, and drug administration. Medication errors can lead to patient discomfort, prolonged hospitalization, patient disability or death, increase in health care costs associated with hospitalization, increased medical liability for health care providers, and higher economic burden for the country.

The most commonly reported errors in both pediatric and adult patients are due to the following :

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  Wrong choice of medication

  
  
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  Incorrect dosage

  
  
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  Incorrect frequency of administration

  
  
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  Wrong route of administration

  
  
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  Delayed drug administration

  
  
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  Failure to recognize drug interactions

  
  
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  Failure to monitor for adverse effects

  
  
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  Inadequate communication among the providers, patient, and family

  
  
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  Inadequate system safeguards