Incidence of medical error and adverse outcomes on a pediatric general surgery service

doi:10.1016/S0022-3468(03)00396-8

Journal of Pediatric Surgery

Volume 38, Issue 9, September 2003, Pages 1361-1365

https://doi.org/10.1016/S0022-3468(03)00396-8 Get rights and content

Abstract

Background/purpose: The Institute of Medicine has identified medical error as a leading cause of death and injury, with deaths resulting from medical error exceeding those caused by motor vehicle collisions, breast cancer, or AIDS. The authors examined the incidence and sources of medical error in relation to adverse events on a pediatric general surgery service.

Methods: All intensive care unit (ICU) and ward admissions to 2 staff pediatric general surgeons during a 1-month period were identified prospectively and in-patient care was reviewed daily by a 3-person panel consisting of a staff surgeon, a surgical fellow, and a nonmedical observer. Medical errors, identified through daily patient encounters, nursing rounds, medical rounds, and chart examinations, were evaluated based on type, hospital setting, personnel involved, and outcome. Adverse outcomes were evaluated based on type and contributing factors.

Results: Our study group included 64 patients. A total of 108 errors were identified; 28% of these errors resulted in adverse outcomes. One or more medical errors were identified in the care of two thirds of patients (43 of 64), with medical error contributing to adverse outcomes in one third of patients (21 of 64). Errors occurred most frequently in communication, postoperative monitoring and care, and diagnosis, with errors in postoperative care and diagnosis having the highest likelihood of resulting in an adverse outcome. Seventy-four adverse outcomes were identified in 31 patients; 35 (47%) of these outcomes, occurring in 21 patients, were attributable to medical error. The most common adverse outcomes identified were additional nonoperative procedures, of which, 92% resulted from medical error. There were no deaths.

Conclusions: Medical error occurs in more than one half of hospital admissions on a general pediatric surgery service and contributes to a substantial number of adverse outcomes.

Section snippets

Materials and methods

This study was conducted at The Hospital for Sick Children in Toronto and was approved by the institutional Research Ethics Board. All patients admitted under the care of 2 attending pediatric general surgeons to either a general surgical ward or the neonatal intensive care unit during a 1-month period were prospectively identified and studied. Day-surgery patients, patients admitted under the medical service to the pediatric intensive care unit, and patients admitted to other medical services

Results

Sixty-four patients (42 boys and 22 girls) were admitted and evaluated during a 1-month period, including 13 neonates (<30 days) and 51 children ages 1 month to 17 years. Fifty-one patients (80%) underwent an operative procedure; 13 patients had nonoperative surgical care.

These 64 patients had 75 hospital admissions during the study period. Fifty-four patients were hospitalized once. Eight patients were hospitalized and then readmitted for surgical complications. Two patients were readmitted

Discussion

Although it is widely recognized that medical error is a significant public health concern, it is difficult to estimate the actual incidence of medical error. Not all mistakes in medical management cause measurable harm to patients, yet most have that potential. Conversely, not all harm caused to patients by medical treatment results from preventable error. For example, prophylactic antibiotics, when indicated, should be administered before making the incision. Failure to administer the

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2021, Journal of Pediatric Surgery
Citation Excerpt :
Errors occurred in communication, postoperative monitoring, patient care and diagnosis. The authors detected no deaths associated with complications [20]. Likewise, we did not confirm any mortality related to medical error in our present study.
Besides surgical complications, a variety of adverse events may affect patients’ comfort and outcome. The purpose of this prospective study was to identify the incidence and impact of all unexpected events in pediatric surgical patients.
All unexpected events that occurred in our department during the period of February 2017–July 2018 were prospectively assessed. Complications associated with surgery, non-surgical treatment, errors and organizational problems were included. Events were classified using a modified version of Clavien–Dindo. Sentinel events were defined as death, serious injury, or the risk thereof (grade IV-V). Organizational events were analyzed separately. All events were discussed during morbidity and mortality-conferences, and the results and measures were documented.
Unexpected events occurred in 297 of 1605 patients (18.5%), of whom 1124 (70%) had undergone surgery. More than half of all events were not associated with an operation (n=237; 54%). The severity of all events was mostly minor (grade I-IIIb; n=410; 94%). Twenty-eight sentinel events (IV-V) occurred (6% of all events). Twenty-two (2%) patients died; however, none of these deaths were related to surgery. The top 5 events included organizational problems in 78 instants (18%), wound healing disorders in 44 (10%), recurrence of initial problems in 36 (8%), dislocation of indwelling catheters in 26 (6%) and bleeding in 16 (4%). Errors were identified in 15 patients (3%). We derived 10 changes of concepts of management or treatment.
The incidence of unexpected events in pediatric surgical patients is high when complications associated with surgical and non-surgical treatment and organizational alterations are documented prospectively. In our study, most events were minor and did not substantially affect patients’ outcomes. Prospective assessment helped to identify organizational shortcomings and develop preventive strategies.
Lessons Learned: Use of Event Reporting by Nurses to Improve Patient Safety and Quality
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The Magnet Recognition Program encourages nurse-initiated, data-driven quality projects. Using data gained from medical error event reporting has been cited as a strategy to improve safety and quality. This article describes a process by which nurses at the Children's Hospital Boston increased error reporting and used knowledge gained from event reports to provide education and implement practice changes. The medical and surgical units experienced a 35% increase in reported events and a decrease in the severity level of events over a 2-year period. Meaningful data from event reporting systems are critical in helping nurses develop interventions to prevent errors. The Magnet Model components are illustrated in the steps of this project.
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Underreporting of surgical adverse events limits the ability to identify quality and safety issues. Automated screening of the clinical information system (CIS) can improve case capture and reduce dependency on self-reporting. We compared screening of a CIS to self-reporting for identifying unplanned reoperation and also examined the relationship between causality and probability of reporting.
Between 2005 and 2009, all unplanned reoperations identified by automated screening of databases were reviewed and classified according to causality. Comparison was made to cases self-reported to departmental morbidity and mortality; conditional probability analysis assessed the likelihood of reporting as a function of causality.
Of 104,938 operations performed, automated CIS screening identified 1,010 cases requiring unplanned reoperation; 23.6% were self-reported to morbidity and mortality; the probability of reporting varied widely depending on causality.
Screening of a CIS for adverse events requiring reoperation revealed significant underreporting, with additional bias in reporting based on underlying causality.
Disaster Drill Exercise Documentation and Management: Are We Drilling to Standard?
2008, Journal of Emergency Nursing
Medical errors are known to occur even in a controlled setting with adequate resources. The few studies on mass-casualty events and disaster exercises suggest errors may be amplified in these situations. We hypothesized that both the documentation and medical care provided during a pediatric disaster drill would be substandard when compared with routine care at the same institution.
Charts from the disaster exercise and matched charts from actual admitted patients were retrospectively reviewed for the presence of triage classification, allergies, weight, physical exam, vital signs, diagnosis, disposition time, disposition location, disposition instructions, and disposition vitals signs and for the appropriateness of diagnoses, medications, procedures, and disposition. Errors were quantified and classified into negligible, likely to cause temporary harm, or potential to cause admission or permanent harm. The drill charts were compared to actual charts by Fischer’s Exact Test.
Drill charts contained a significantly greater proportion of errors in regards to performance of procedures, administration of medication, and accuracy of diagnosis. Sixteen percent of these errors were judged as having the potential to cause permanent harm or admission. The exercise charts contained a significantly greater number of omissions in documentation in 9 of the 10 areas evaluated.
Both the documentation and the quality of care provided during our exercise were deficient when compared with conventional care. Opportunities allowing providers to clearly document pertinent information, and linking of this documentation to relevant prompts and algorithms may minimize this potential for error.
Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit
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To determine the incidence, type, and stage of occurrence of medication errors and potential and actual adverse drug events (ADEs) in a pediatric intensive care unit (ICU) using trained observers. The preventability and severity of ADEs and the system failures leading to medication error occurrence were also investigated.
Prospective, direct observation study.
A 16-bed pediatric medical/surgical ICU at a tertiary care academic medical center.
One enrolled nurse caring for at least one pediatric ICU patient age <18 yrs was randomly chosen during each observation period.
Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort.
Medication errors and potential and actual ADEs were identified throughout the entire medication use process. The 26 12-hr observation periods included 357 reviewed written orders and 263 observed doses. The study observers identified 58 incidents, which were subsequently classified by the evaluators according to clinical importance, severity, and preventability. Fifty-two of these incidents were considered medication errors; six incidents were determined to be nonpreventable ADEs. Of the 52 medication errors, 42 (81%) were considered clinically important. Potential ADEs comprised 35 (83%) of these important medication errors; the other seven (17%) were classified as actual, preventable ADEs. Overall, the actual and potential ADE rate occurred at 3.6 events and 9.8 events per 100 orders, respectively.
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Basic science reviewIncidence of medical error and adverse outcomes on a pediatric general surgery service

Abstract

Section snippets

Materials and methods

Results

Discussion

Surgery

Lancet

Incidence of adverse events and negligence in hospitalized patientsResults of the Harvard Medical Practice Study I

N Engl J Med

The nature of adverse events in hospitalized patientsResults of the Harvard Medical Practice Study II

N Engl J Med

Basic science review
Incidence of medical error and adverse outcomes on a pediatric general surgery service