Trigger tool detects harm in pediatric inpatients

By Will Boggs MD

NEW YORK (Reuters Health) - The newly developed Pediatric All-Cause Harm Measurement Tool (PACHMT) improved detection of harms in pediatric inpatients in a recent pilot study.

Using the tool, researchers found a rate of 40 harms per 100 patients admitted, and at least one harm in nearly a quarter of the children in the study. Close to half of the events were potentially or definitely preventable.

"Safety is measured inconsistently in health care, and the only way to make progress to improving these rates of harm is to understand how our patients are impacted by the care they receive," Dr. David C. Stockwell, from George Washington University and Children's National Medical Center, Washington, D.C., told Reuters Health by email. "Therefore we would like to see wider adoption of active surveillance of safety events with an approach like the PACHMT. While not replacing voluntarily reported events, it would greatly augment the understanding of all-cause harm."

Dr. Stockwell and colleagues modeled the PACHMT after the Institute of Healthcare Improvement's (IHI's) Global Trigger Tool, which includes 55 triggers and has been used successfully in a variety of adult settings.

Dr. Stockwell's team used the PACHMT to estimate harm rates across six children's hospitals as part of their effort to determine the feasibility and appropriateness of the tool for assessing all-cause harm in hospitalized children.

Clinical and physician reviewers at each site received training based on previous work by IHI and the Children's Hospital Association.

In 600 randomly chosen charts (100 from each hospital), PACHMT detected 1093 triggers, resulting in identification of 204 harms. An additional 36 harms not detected by PACHMT were identified during chart review.

The positive predictive value of the 51-item PACHMT trigger list was 22.0%, according to the May 18 Pediatrics online report.

Most harms (68.5%) were in National Coordination Council for Medication Error Reporting and Prevention Category E (contributed to or resulted in temporary harm to the patient and required intervention). There was one Category I harm (contributed to or resulted in the patient's death), and it was deemed definitely not preventable.

Overall, there were 40 harms per 100 patients admitted (54.9 harms per 1000 patient-days), with at least one harm identified in 146 patients (24.3%). Nearly half the harms (45.0%) were documented as either probably or definitely preventable.

The most common harms were intravenous catheter infiltrations/burns, respiratory distress, constipation, pain, surgical complications, and skin rash, bruising, or burn.

"In the 15 years since the clarion call by the Institute of Medicine regarding patient safety, there is still a great deal of work to do," Dr. Stockwell said. "The first step in making real change is to work to understand our safety events, whether they are from errors or from complications of care. Once we understand the scope of these events, there is great progress that can be made."

"Because this work was only intended to be a pilot study, future research should focus on editing the PACHMT to establish the next-generation pediatric global trigger tool, conduct a formal study to establish harm rates and epidemiology, and determine the operating characteristics of this tool, with an eye toward integration into the electronic medical record and eventual automation," the researchers concluded.

Dr. Andrew Carson-Stevens, Patient Safety Research Lead at Cardiff University in the UK, told Reuters Health by email, "Signals for where to intervene generated by patient safety tools like trigger tools and safety incident reporting systems must be used to prioritize the focus on where to improve areas of practice that are both most common and harmful to children. Health care professionals must have courage to explore both, 'what went wrong?' as well as 'what enabled us to deliver great care?' in their pursuit of safe, high-quality care for children."

The Children's Hospital Association partially supported this research. Two coauthors are partially employed by Pascal Metrics, a federally certified patient safety organization; another coauthor has served as a paid expert witness in cases about patient safety.

SOURCE: http://bit.ly/1R024l4

Pediatrics 2015.

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