Unexplained deaths in a children's hospital. An epidemiologic assessment.
During a nine-month period, July 1980 through March 1981, the mortality rate for patients on the cardiology ward of a children's hospital was 43.1 deaths per 10,000 patient-days, as compared with 11.0 deaths per 10,000 patient-days during the preceding 54 months. Twenty-five (76 per cent) of 33 infant deaths during this nine-month period occurred between midnight and 6:00 a.m., as compared with 1 of 10 infant deaths during a separate 27-month period (P less than 0.001). Although nearly all deaths occurred in patients with serious congenital heart disease, epidemic-period deaths were more likely to have an unexpected timing and a clinical pattern consistent with digoxin toxicity. In four patients, forensic and clinical digoxin measurements suggested that an intravenous overdose of digoxin had been administered shortly before death. Although a review of nursing schedules revealed a strong association (relative risk, 64.6) between infant deaths and the duty times of a particular nurse, the cause of the epidemic remains unclear. The study led to suggestions that the hospital strengthen central control over procedures for dispensing medicines and implement a system for monitoring the occurrence of deaths by time and place within the hospital.
D004077:Digoxin / Q000506:poisoning; D004812:Epidemiologic Methods; D005554:Forensic Medicine; D006331:Heart Diseases / Q000401:mortality; D006746:Hospital Bed Capacity, 500 and over; D006757:Hospital Units / Q000592:standards; D006776:Hospitals, Pediatric / Q000592:standards*; D006782:Hospitals, Special / Q000592:standards*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000592:standards; D008508:Medication Errors; D009026:Mortality; D009864:Ontario; D010380:Peer Review; D010561:Personnel Staffing and Scheduling; D012306:Risk; D013029:Space-Time Clustering; D013995:Time
D004077:Digoxin