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Pediatric Safety and Quality

Pediatric inpatient safety and quality of care are dynamic and complex phenomena. Our intent is to inform the reader about efforts underway by pediatric stakeholders and specialty groups and to understand where credible information can be accessed pertaining to patient safety and quality in the provision of care for the hospitalized child. Over the past several years, pediatric groups have partnered to improve general understanding, reporting, process improvement methodologies, and quality of pediatric inpatient care. These collaborations have created a robust program of projects, benchmarking efforts, and research. This chapter discusses general findings about safety and quality; major initiatives by agencies, groups, and collaborations; a guide to synthesis documents surrounding quality care and evidence-based practice for specific areas of pediatric care; and recommendations about how we can move pediatric safety and quality forward in practice and in the policy arena. Patient safety literature and associated findings on adverse events for pediatric patients have been widely disseminated. Much of the focus has centered on medication errors—the most frequently reported adverse event for both adult and pediatric patients. Indeed, the Institute of Medicine (IOM) reported that medication errors are the most common, yet preventable, type of harm that can occur within the pediatric population, and Bates reported that when pediatric medication errors occur, these patients have a higher rate of death associated with the error than adult patients. Medication errors, however, are only one potential adverse event for hospitalized children. Slonim and colleagues found 1.86–2.96 medical errors per 100 discharges of hospitalized children. Four distinct challenges confront those conducting research and caring for children. These four related issues are each problematic, but in concert they create a high-risk environment for hospitalized children. Following are the four issues for pediatric patients, summarized from Beal and colleagues: • Development: As children mature both cognitively and physically, their needs as consumers of health care goods and services change. Therefore, planning a unified approach to pediatric safety and quality is affected by the fluid nature of childhood development. • Dependency: Hospitalized children, especially those who are very young and/or nonverbal, are dependent on caregivers, parents, or other surrogates to convey key information associated with patient encounters. Even when children can accurately express their needs, they are unlikely to receive the same acknowledgment accorded adult patients. In addition, because children are dependent on their caregivers, their care must be approved by parents or surrogates during all encounters. • Different epidemiology: Most hospitalized children require acute episodic care, not care for chronic conditions as with adult patients. Planning safety and quality initiatives within a framework of “wellness, interrupted by acute conditions or exacerbations,” presents distinct challenges and requires a new way of thinking.