Patient Safety in Pediatrics: a Developing Discipline

Abstract

The publication of the breakthrough report “To Err is Human” by the Institute of Medicine was the launch of patient safety initiatives all over the world. In the intensive care unit (ICU) of the Erasmus MC-Sophia Children’s Hospital this resulted in the institution of a multimodal patient safety management system under the name Safety First in 2005. This system now includes nine major elements, representing monitoring and intervention activities. In this thesis we report on the results and the implementation of the patient safety management system called Safety First.

Outline of this thesis: In part I the concept of patient safety and the Safety First project are introduced. The rationale for selecting the elements of the patient safety management system is explained. As preventable mortality and morbidity are the public focus as outcome parameters for quality and safety of care, we have studied very long stay patients in our ICU (chapter 2). The goal of this study was to determine characteristics and mortality in these patients as well as modes of death. Chapter 3 presents an evaluation of potentially preventable deaths in our ICU. An important question was whether five years of patient safety efforts had resulted in fewer potentially preventable deaths. Part II reflects on the difficulties in monitoring adverse events. In chapter 4 we present numbers and types of adverse events identified with real time physicians’ registration during a 3-month period in general pediatric practice. The next chapter is a study into adverse events in the surgical pediatric ICU in a 2-year period. We combined the physicians’ registration with the Trigger Tool methodology as developed by the Institute for Healthcare, Boston, USA. The goals were to determine the rate and nature of the adverse events and to compare the two methods. In part III a number of elements of Safety First are described, as well as other studies into patient safety issues relevant to bedside ICU care. Chapter 6 brings the results of critical incident analysis with a focus on the factors contributing to the incident and the resultant recommendations. The next study evaluated the availability and reliability of drug formularies used in our ICU, which are crucial in safe drug prescription. In chapter 8 we discuss the safety of routine MRI scans in preterm infants at 30 weeks gestational age, as reflected by safety incidents and adverse events. In the next chapter, safety focused Mortality and Morbidity conference reports were scrutinized for numbers and types of recommendations stemming from these meetings. Chapter 10 is a study about nursing protocol violations established with the Critical Nursing Situation Index. Part IV describes a study of safety culture in the ICU, as it emerged from a safety attitude questionnaire administered to all staff. We aimed to compare findings to benchmark data and explore any deficiencies. In the general discussion in part V the results of the studies are commented on and future directions are given, including guidelines for optimal implementation of a patient safety management system and future benchmarking.