Patient Safety for Infants and Children in Academic Medical Center Hospitals:

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Patient Safety for Infants and Children in
Academic Medical Center Hospitals

• Organizational and Human Factors Related to
  Harmful Medication Event Outcomes

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Project Objective

• To identify human organizational factors
  related to medication events in infants and
  children

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Methods

• Medication error-event data
• 23 Academic medical centers
• Participating in a web based reporting system
• Years 2001 to 2004

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Data Source Patient Safety Net

• Development history
• University HealthSystem Consortium
• steering committee of 15 member
  organizations April 2001
• Created Patient Safety Net Goals
• Standardized taxonomy
• Remove barriers to event reporting
• Real time analysis/management of events

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Key Characteristics of UHC Patient Safety Net?

• Easy web based reporting of adverse events, near
  misses, unsafe conditions that involve patients,
  staff and visitors
• Reports available immediately to managers
• Organizations can compare their data for
  benchmarking and identifying areas of concern
• Integrates current HIPAA regulations

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Population studied

• Patients from 0 to 18 years
• Infants less that 30 days
• Children from 1 month to 18 years
• Pediatric ICUs , intermediate oncology units
• Neonatal ICUs intermediate units
• Compared to adults over 18 years

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Organizational Human Factors Conceptual Model

• Rooted in Reason organizational accident model.
• Complex industrial systemsID-factorsproduce
  accidents
• ID methods for prevention
• ID change of events that lead to adverse
  eventserrors
• Trace back through organizational hierarchy to
  staff conditions and context the incident
  occurred

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Organizational Factor Framework of Reason and
Vincent

• Patient factors
• Language barrier, disability
•   Task factors
• Availability protocols, test results
•   Individual (Staff) Factors
• Knowledge, skills, and experience
•   Team factors
• Communication, Supervision, leadership

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• Organizational Factors Contd
• Work/environmental factors
• staffing levels, workload
• Maintenance of equipment, building
• Organizational factors
• Policy standards and goals, Financial constraints
• Institutional factors
• -External regulatory bodies
• -Medical-legal environment

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Harm Score

• Development based on a previous Standardized
  Taxonomy of Medication Errors
• Consists of 10 levels of severity
• Ranging from unsafe conditions to death
• Levels 1-5 Event does not reach patient
  near misses
• Levels 6-10 Harmful event reaches the patient

National Coordinating Council for Medication
Error Reporting and Prevention (NCC MERP) 1998.
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• Harm Score Web input Screen

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Factors Web data screen
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Results

• Children in pediatric units had a harmful
  error rate of 5.6 out of a total of 1405 errors
• Infants in Neonatal units had a harmful error
  rate of 8.9 out of a total of 755 errors
• Adults over 18 years had a a harmful error rate
  of 10.5 out of a total of 20,601 errors

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Harm Score Distribution for Adults gt 18,
Pediatric Neonatal Units
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Observations

• This study provides evidence of specific human
  and organizational factors that are related to
  medication errors that necessitate additional
  treatment, are life threatening, or result in
  death.
• There is some variation in the distribution of
  medication errors in children and infants

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Implications for Policy and Practice

• Identification of organizational factors related
  to harm can be used to target error-event
  prevention programs.
• Provides evidence to support the use of
  standardized web-based event reporting systems.