Children are commonly harmed by adverse events in intensive care units
Research Activities, November 2009
When adverse events (AEs) occur in pediatric intensive care units (ICUs), one-third of such incidents result in physical injury to children, while two-thirds harm children in other ways, according to a new study. Johns Hopkins researchers analyzed data collected over a 2-year period describing safety incidents taking place in pediatric ICUs around the country. Providers were able to report such incidents and near misses through a Web-based incident reporting system called the Intensive Care Unit Safety Reporting System. During the 2-year study period, 23 pediatric ICUs reported 464 incidents. Physical injuries harmed children in 35 percent of the incidents, while “any harm” occurred in 60 percent. There were three patient deaths from such incidents. Medication or therapy AEs accounted for 40 percent of all incidents and resulted in more near misses than other types. Compared with other incident types, medication-related ones were less likely to result in harm or physical injury.
Line, tube, and airway events accounted for one-third of all cases, and were associated with more harm than other types of events. Equipment/devices were involved in 13 percent of AEs. Patient contributing factors were the strongest predictor of harm, and training and education factors also played a role. To improve safety in pediatric ICUs, the researchers recommend developing protocols for high-risk procedures involving lines and tubes; improved monitoring; and staffing, training, and communication initiatives. The study was supported in part by the Agency for Healthcare Research and Quality (HS11902). See “Pediatric safety incidents from an intensive care reporting system,” by Julia Lynn Skapik, M.D., M.P.H., Peter J. Pronovost, M.D., Ph.D., Marlene R. Miller, M.D., and others, in the June 2009 Journal of Patient Safety 5(2), pp. 95-101.