A tool to prevent medical errors in pediatric inpatients has discovered that almost half of the harms in patient charts were preventable.
A pilot study to measure the tool’s effectiveness made this discovery.
Researchers reviewed 600 charts, 45% of which contained medical harms assessed as being potentially or definitely preventable.
Researchers assert that this resulted in the rate of 40 harms per 100 patients admitted and 54.9 harms per 1000 patient days.
The Pediatric All-Cause Harm Measurement Tool was designed by the authors to detect triggers. Triggers are designed as a medical record based hint that triggers the search of the medical record to determine whether an adverse event might have occurred.
During the chart review, the tool identified 85% of all harms and also identified 36 triggers at least once during the chart review.
Researchers determined that 24.3% patients experienced 1 or less harms, while 8.5% patients experienced multiple harms.
The most common of these harms were intravenous catheter infiltration/burns, respiratory distress, constipation pain, and surgical complications. 68% of these harms were rated level E on the National Coordination Council for Medication Error Reporting and Prevention harm scale.
The author said that 9.2% of harms were also identified through voluntary reporting and not just through the Pediatric All-Cause Harm Measurement Tool. However, they assert that only between 2 and 8% of harms are captured through this system of voluntary reporting even though it is the main method of reporting harms in most hospital.
The Pediatric All-Cause Harm Measurement was modeled off the Institute of Healthcare Improvement Global Trigger Tool used in adult settings.
The rate of harms captured by the tool was consistent compared to the rate detected in high-volume tertiary care adult-based institutions.