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Stepping up Pediatric Patient Safety (Chris Dickinson)
- 1. 1 CS Mott Children’s Hospital: Patient Safety Issues Chris J. Dickinson, M.D. Chief Medical Officer Children’s & Women’s
- 2. 2 CS Mott Children’s Hospital
- 3. 3 CS Mott Children’s Hospital
- 4. 4 CS Mott Background - I • Part of University of Michigan Health • Single campus – Mott attached to adult University Hospital – Medical and Nursing Schools on same campus – School of Public Health across the street • Located in Ann Arbor, Michigan – Population 116,000 without students – Population almost doubles on football Saturdays – 45 miles from Detroit
- 5. 5 CS Mott Facts - II • 234 pediatric beds new building 5 years old – 128 acute care – 60 ICU – 46 neonatal ICU • 20 OR’s – IR, MR/OR, 3 cardiac OR’s • Emergency Department – 36 beds & 25,000 visits/yr • Attached out-patient space with infusion area
- 6. 6 Background-III • 50 women’s obstetric beds located in the Von Voigtlander Women’s Hospital – 9th floor same building • NICU on 8th floor – 4,800 births/year – Useful for critically ill mothers or babies • Exit procedures where the baby is delivered by c- section but placenta is not • Baby then placed on ECMO and cord cut • Placenta delivered and maternal wound closed – OB clinics and fetal diagnostic center adjacent
- 8. 8 Significant events or injuries Slide concept adapted from James Reason, Managing the Risks of Organiza2onal Accidents, 1997 Super Heroes in Med Safety Joyce Some poten7al errors: • Medica7on Selec7on • Concentra7on • Route • Interac7on or Allergy Wri2ng a single medica2on order Annually In Mo@ we administer ~1.2 million drug doses Resident Nurse Med Manager Pharmacist If together we are 99.9% accurate 3-4 errors reach the patient every day
- 9. 9 Root Cause Analysis of Med Errors • Many medications used in pediatrics are not commercially available as liquids and must be compounded • Prescribers have no control over the concentration of any compounded medication – Pharmacies can and do compound at many different concentrations for a single drug – Problem when patients arrive from outside and family says they give 1 tsp of med • There is no single “gold-standard” recipes for compounding which can lead to: – Concentration errors – Stability concerns
- 11. 11 Solution • Standards developed • Website created – mipedscompounds.org – Includes standards, recipes, references •
- 12. 12 Pediatric Safety Issues • Often similar to adult issues but there are significant differences – Children’s safety should be informed by but not driven by adult issues • There is a need for better pediatric specific quality metrics for children’s hospitals to focus on • Children’s Hospitals will need to work together (Solutions for Patient Safety) – Share data and ideas