Small Patients Need Big Safety and Reliability Goals

Added on Apr 11, 2016

By Diana Mahoney, Editorial Director

“Children are not little adults.” It’s a well-worn expression, particularly in health care circles where the differences between pediatric and adult care are well-understood, butzero_harm_logo_2x2 it still comes to mind when teasing out the drivers (and detractors) of safety and reliability in the pediatric setting.

The challenges, problems and concerns that influence the safety of pediatric care are different from those that contribute to harm in the adult care setting. Therefore, solutions and interventions must address and reflect these differences in order to protect children from serious, preventable harm.

Patient safety is a relatively young discipline, entering the public consciousness in a big way beginning in the 1990s, with eye-opening studies—including the landmark Institute of Medicine report To Err Is Human: Building a Safer Health System—documenting the scale of harm caused to patients by medical errors. These studies gave rise to numerous quality measures designed to improve patient safety, most of which were developed based on research and analyses of the adult health care system. But, and here it is, children are not little adults.

babyMedical errors and patient harm differ in several ways for children compared with adults. For example, children are at greater risk of medication errors than adults. In fact, research has shown that the potential for adverse drug events within the pediatric inpatient population may be three times greater than for hospitalized adults.[1]

Safely administering medications to hospitalized children is more complex because of the differences in children’s weight, body surface area, organ system maturity and ability to metabolize and excrete drugs; the lack of standardized dosing regimens; and the fact that some drugs are being used in children based on limited evidence and without specific dosing guidelines.

In addition, computerized physician order entry systems that are designed for adults have limited effectiveness in reducing pediatric medication errors.[2] And efforts that eliminate catheter-related bloodstream infections in adults do not have the same effect for children.[3] 

Variation of this sort is the nemesis of High Reliability, according to Katy Welkie, chief executive officer of Intermountain Primary Children’s Hospital in Utah. “Doing the right thing, the right way, every time, is especially difficult when the right thing to do is dependent on such a wide range of factors,” she said in a recent interview for Press Ganey’s Industry Edge.

Research bears that out. A 2015 study evaluating a tool designed to detect harmful events in pediatric inpatient environments identified 40 harmful events per 100 patients admitted and 54.9 harms per 1,000 patient days across the six academic children’s hospitals participating in the pilot test. Modeled after the Institute for Healthcare Improvement’s Global Trigger Tool, the Pediatric All-Cause Harm Measurement Tool detects triggers in the pediatric electronic medical record to determine cases of patient harm. The researchers in the pilot test examined 100 randomly selected inpatient records at each of the six participating hospitals and identified 240 harmful events (with multiple harms often linked to a single patient). Of the 240 events, 108 were considered to be potentially or definitely preventable.

These numbers are unacceptable, according to Welkie. “Safety is our highest priority. We can win awards, provide compassionate care and even have miraculous breakthroughs in science, but if we fail to keep our patients safe, all of that pales.”

Keeping patients safe in the pediatric setting requires change at the local and national levels. At the local level, for example, the leadership team at Intermountain Primary Children’s Hospital has undertaken a multiyear journey to High Reliability, targeting the elimination of preventable errors across all aspects of care. Importantly, the journey, which is based on a Zero Harm model, is designed to influence how leaders view and analyze safety events and investigate causes, and inform the way units and services are organized for patient safety.

“The Zero Harm model comprises a set of tools that empower staff to listen and respond and create the best environment for every child to be safe and helped,” Welkie stressed.

The model’s success to date—including 90% or higher cumulative compliance on every national patient safety goal, a 95% reduction in ventilator-associated pneumonia rate, a 75% reduction in central line-associated bloodstream infection rate and a 25% reduction in serious safety events—has led to an expansion of the program to all Intermountain Healthcare facilities.

“The work at Intermountain Primary Children’s Hospital is an excellent example of applying High Reliability organizing to improve patient safety,” said Dr. Gary Yates, managingpartner of Strategic Consulting at Press Ganey. “In many ways, the children’s hospital community, working together, is raising the bar for performance for the entire industry, starting with their agreement on Zero Harm as the goal.”

At the national level, improving the safety and reliability of care has risen to its rightful place at the top of the pediatric health care agenda. Through Solutions for Patient Safety (SPS), a national network of more than 80 children’s hospitals, these organizations are banding together in the journey toward High Reliability. Built on the idea that children’s hospitals should collaborate rather than compete with one another on safety, “we adhere to an ‘all teach, all learn’ philosophy,” Welkie said. “We share our safety successes and failures, and everyone has the opportunity to learn from both.”

Although children’s hospitals are making meaningful forward progress on the road to High Reliability, “we have a long way to go,” said Welkie. “The reality is that there are very few processes that children’s hospitals perform correctly nearly 100% of the time.” Although providers strive for perfection when it comes to following evidence-based protocols, central line bundles, correct diagnosis and so forth, “we consider 90% to 95% to be excellent performance. This is a far cry from the Six Sigma standard that is the benchmark in other industries.”

For that reason, Welkie stressed, it’s time to redefine excellence in pediatric patient safety. “The only acceptable goal has to be Zero Harm.”

Editor’s note: To learn more about efforts to improve the quality and safety of pediatric health care, join pediatric health care leaders from across the country this week at the Children’s Hospital 2016 Press Ganey Leadership Summit in Palm Beach, Fla., April 13–14.


[1] Kaushal, R., D.W. Bates, C. Landrigan, et al. 2001. Medication errors and adverse drug events in pediatric inpatients. Journal of the American Medical Association 285:2114–2120.

[2] McPhillips, H.A., C.J. Stille, D. Smith, et al. 2005. Potential medication dosing errors in outpatient pediatrics. Journal of Pediatrics 147(6):761–767.

[3] Miller, M.R., M. Griswold, J. Mitchell Harris II, et al. 2010. Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI’s Quality Transformation Efforts. Pediatrics 125(2):206–213.