Grant Visscher was born on April 8, 2008, with a heart defect. He was 11 days old when an experienced nurse replaced his feeding tube and used auscultation and visual aspiration to verify its placement. Throughout the day, Grant's mother, Deahna, watched him begin to blow milky white bubbles; over time, his lips turned blue. His parents tried to tell staff something wasn't right.
Just two days short of going home, Grant died from a placement of the feeding tube into his trachea instead of his stomach via the esophagus. Milk flowed into his tiny lungs, an error that was preventable.
It changed the lives of the Visschers and continues to spur the spread of evidence-based feeding tube procedures that protect children from the same outcome. "I lost my son to this, and I don't want anyone else to lose their child because of it," says Deahna, now a passionate patient safety advocate.
According to the Child Health Patient Safety Organization® (PSO), nasogastric (NG) tube misplacement is just one of the pediatric safety issues children's hospitals need to focus attention on. "As crazy as this sounds, we didn't know how much harm we were causing," says Elizabeth Mack, M.D., M.S., pediatric intensivist, division chief, pediatric critical care, at Medical University of South Carolina Children's Health in Charleston.
"We had to get serious about capturing all the preventable harm." After years of work and data collection in the PSO, hospitals can now see the causes of the most serious safety events to prevent harm that is likely to repeat.
Serious harm in children's hospitals is rare, so aggregating these events from more than 60 children's hospitals in the PSO provides a broader view of risks. "We're at the point in the PSO where we're able to look under the hood of precursor events and understand where harm is coming from," says Jackie Valentine, director of patient safety at Seattle Children's Hospital.
She knows what it's like to sit across the table from families when something has gone seriously wrong in their child's care. She also sees the toll these events take on the child's caregivers. "There will never be a day the provider won't relive that situation," Valentine says. "We all have to do our part to prevent harm from happening."
Jeanann Pardue, M.D., chief quality officer at East Tennessee Children's Hospital in Knoxville, says hospitals need to shore up their weaknesses now. "That means working diligently to address the problems we see, even those we don't typically think about, and talking openly about the culture that still allows them to happen," she says.
From the aggregate PSO data, here are six patient safety concerns with risk for repeat harm in any children's hospital. Hospitals don't need to wait for a tragic outcome like Grant's to occur before changing practices.
Nasogastric tube misplacement
Five years after Grant's death, Deahna was on rounds in her role as a patient safety advocate when a NICU nurse shared the story of an infant who died because his tube was placed incorrectly. The nurse cited this as the reason the hospital uses a different method for placing feeding tubes—she didn't know she was talking to the infant's mother.
For Deahna, it validated that people had learned from Grant's death. But despite this moment and obvious progress, she's frustrated by the lack of awareness of the proven practices that make this procedure easier and safer.
At a conference where she spoke last year, Deahna asked a room of neonatal nurses if they used auscultation and visual aspiration. Many raised their hand. "I asked them, ‘Why do you use this method?' They responded it was what they were taught, and they'd never had a problem with it," she says. "I told them Grant's nurse was very experienced. She had been doing feeding tubes for over 20 years and still made a mistake."
National studies estimate at least 25 percent of children using NG tubes are at risk for harm, and the consequences can be catastrophic. The risk increases for neonates, children with neurologic impairment, children who are sedated, unconscious, or critically ill, and children with reduced gag reflex. Hospital teams should discuss if current nursing practices place patients at risk, and act immediately to remove outdated practices.
Thermal injuries
Thermal injuries are often considered low risk. But when organizations like East Tennessee Children's Hospital use a gap analysis, they may discover they have a clear patient care vulnerability and potential for a serious safety event. "The thermal injury risk assessment showed us a gap we had in our hospital that we didn't know we had," says Pardue. "Until then, these type of injuries were considered low-level events and wouldn't have risen to a priority until something significant occurred."
Hot or cold thermal devices like heating pads, even over-the-counter products that are perceived to be safe, can cause significant harm to children. Misusing products or using items not intended for patient care can also lead to severe burns, pressure ulcers, blisters and wounds that require additional medical treatment.
After completing a thermal injury risk assessment, one hospital found staff members were using hot water from a coffee machine to warm breast milk because bottle warmers weren't available. This could lead to milk heating to scalding temperatures. As a result, the hospital purchased more bottle warmers and educated staff members on the correct use.
This situation is one example of how work-arounds happen when employees don't have the right patient care equipment. There are risks created in pediatric patient care that thermal product manufacturers don't consider. For example, providers should first assess if a child with a heating pad is sitting against the bed—the pad shouldn't be placed where the patient leans against something.
They should also consider if the patient is on medications that cause drowsiness, or if the patient is immobile, non-verbal or has diminished sensation. A patient could fall asleep with the pad against the skin or not be able to alert a provider, resulting in a burn.
Medication safety
According to the American Academy of Pediatrics, 6 percent to 11 percent of pediatric inpatients may experience adverse drug events. And more than 20 percent of cases reported to the PSO involve medication errors, which rates higher than all other categories. This includes risks with medication administration, ordering and reconciliation. Medication reconciliation becomes an increased safety concern for children's hospitals when a patient's full medication history isn't available to providers.
Providers could give the wrong medication or dose to a child, creating an adverse drug event that causes patient harm and requires additional medical treatment. The Joint Commission recommends providers involved in a child's care check the accuracy of the medication reconciliation process at admission, each transition of care and discharge from the hospital.
Diagnostic errors and communication
Errors in medical decision making can contribute to missed, delayed and wrong diagnoses, resulting in patient harm. The PSO sees cases that indicate this is a significant contributor to harm. But it's difficult to detect and address because the science is in the early stages. "Our brains are wired in ways that were evolutionarily useful but can interfere with coming to correct conclusions, including diagnostic reasoning," says Daniel Hyman, M.D., chief medical and patient safety officer at Children's Hospital Colorado in Aurora.
"We have to identify ways in which our systems can reduce the likelihood that natural human errors result in harm to patients." Communications failures, which the PSO reports as a top cause of serious and severe moderate harm, are included in this topic. Diagnostic errors represent 17 percent of cases submitted to the PSO—the most serious patient harm was frequently present when communication failures contributed. The PSO is exploring guidance on communication strategies to improve diagnostic safety.
Diabetes care management
Many children's hospitals have specialists who are accustomed to caring for children with diabetes. But for providers who do not specialize in this patient population, managing their care can be a high-risk activity. They may lack sufficient resources, appropriate patient monitoring systems, and access to clinical job aides, and rarely see these types of patients. If symptoms of diabetes complications are not anticipated or recognized early, the outcomes can be life threatening. Hospitals can conduct a risk assessment to identify organizational gaps related to improving the safety and reliability of diabetes care.
Procedural Mishaps
Retained foreign objects:The Joint Commission estimates about 1,500 surgeries a year end with a retained foreign object. An analysis of the PSO database revealed a risk from surgical/ procedural items that weren't included in the pediatric standardized count process. This includes supplies altered to accommodate pediatric use, supplies added after the procedure begins, items found in surgical kits, and guidewires or device fragments. Without adherence to standardized processes, like time-outs and counts, or a high-reliability culture, errors can result in perforation or infection, and death can occur.
Wrong-site surgeries: Across all U.S. hospitals, wrong-site surgeries occur approximately 40 times per week. Children's hospitals frequently report the incidence of wrong-site surgeries to the PSO. While progress has been made in this area, new data from the PSO shows risks with procedures involving difficult-to-mark surgical sites and communication failures between providers.
