Preventable harm occurring to critically ill children.
OBJECTIVE
To develop a trigger tool for identifying adverse events occurring in critically ill pediatric patients; to identify and characterize adverse events and preventable adverse events experienced by critically ill pediatric patients; and to characterize the patients who experience preventable adverse events.


METHODS
Retrospective chart review using a trigger tool.


METHODS
Pediatric intensive care unit of a tertiary, university-affiliated pediatric hospital.


METHODS
A systematic sample of 259 pediatric intensive care unit patients from a 1-yr period.


METHODS
None.


RESULTS
We measured frequency of occurrence (0.19 preventable adverse events per patient-day), severity of harm (78% minor, 19% moderate, 3% serious, no deaths), and type of event (sedation, 22%; skin, 16%; medical device complication, 14%; pulmonary, 13%; and cardiovascular, 11%). Patients who experienced preventable adverse events were younger, had longer lengths of stay, and had higher illness burdens. Preventable adverse events occurred more frequently among surgical patients than medical patients.


CONCLUSIONS
Preventable adverse events occurred fairly frequently in the pediatric intensive care unit, but serious harm was rare. Conditions that increased the likelihood of a preventable adverse event were a) need for sedation or pain control; b) relative immobility; and c) need for vascular devices, feeding tubes, or ventilators. Adverse event prevention strategies that focus on improving patient monitoring under increased-risk conditions and improving early detection and treatment of potential harm will likely be more effective than strategies aimed at general error prevention.
Larsen
Gitte Y
GY
Primary Children's Medical Center, Salt Lake City, UT, USA. gitte.larsen@hsc.utah.edu
Donaldson
Amy E
AE
Parker
Howard B
HB
Grant
Mary Jo C
MJ
D002404:Catheterization / Q000009:adverse effects; D002675:Child, Preschool; D002985:Clinical Protocols; D016638:Critical Illness; D003428:Cross Infection / Q000209:etiology; D004864:Equipment and Supplies / Q000009:adverse effects; D005260:Female; D006776:Hospitals, Pediatric; D006785:Hospitals, University; D006801:Humans; D015278:Intensive Care Units, Pediatric / Q000458:organization & administration*; D007902:Length of Stay; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D012189:Retrospective Studies; D012307:Risk Factors