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Pediatric Update


Pediatric Update

Spring 2006

UCLA Implements New Efforts to Address Medical Errors

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“You have to look at the whole system before you can come up with a good solution. We do that not in an accusatory, blame-oriented manner, but rather in the spirit of problem-solving and education.” —Judith Brill, M.D.

Improving patient safety has become an important national focus in recent years, especially following a 1999 Institute of Medicine report that estimated that as many as 98,000 deaths per year occur as a direct result of medical error—more than the total of motor vehicle accidents, breast cancer and AIDS deaths combined. In addition to resulting in preventable adverse events—injuries as well as deaths—medical errors cost an estimated $29 billion annually.

Mattel Children’s Hospital at UCLA has taken aggressive steps to reduce the risk of such errors. “We know that as medicine has become increasingly complex, there are more opportunities for mistakes to be made,” says Judith Brill, M.D., chief of critical care and vice chair of clinical affairs for the UCLA Department of Pediatrics. “We recognize that the potential for mishaps is real; we are constantly looking for ways to make improvements that will limit these errors.”

Medication errors are a particular concern. Opportunities for error begin with the written order, which can be incorrect or illegible. The pharmacy is then relied on to ensure proper dosing and to consult with the physician if the ordered dose seems to deviate from the standard. The potential for adverse drug interactions must be considered. The dispensing of the drugs can be mishandled, as can the timing and route by which they are given. In pediatrics, where calculations are often necessary to determine weight-and age-specific dosing, math errorscan be made.

The opportunity for medical error is perhaps highest in an intensive care setting, where treatment of acutely ill patients requires coordination of multiple aspects of care. “Errors are rarely the fault of a single person or the result of a single event,” says Dr. Brill.

A good reporting system is key to reducing medical errors. “You have to look at the whole system before you can come up with a good solution,” says Dr. Brill. “We do that not in an accusatory, blame-oriented manner, but rather in the spirit of problem- solving and education.”

Understanding how the culture of medicine affects the likelihood of medical errors and error reporting is an important first step to developing effective strategies to combat them, says Halleh Mir, M.D., UCLA neonatologist. Among the factors to consider, Dr. Mir suggests, are the presence of a hierarchy, the attitude toward reporting error, the fear of legal ramiflcation, and the fear of losing one’s credibility. “Medicine is a team environment where multiple highly trained individuals work side by side,” Dr. Mir says. “In such a system, where error is seen as individual failure, the incentive to report is understandably marginal.”

Dr. Brill heads a quality improvement committee that evaluates the reports that come in, interviews participants, and makes recommendations for system changes as well as educational meetings to reduce the likelihood of future errors. One central strategy stresses the need for the entire healthcare team to remain vigilant against mistakes in even the most routine matters. Another involves building multiple check-off points into the system. Such precautions can help catch medication-ordering errors before it’s too late. When providing anesthesia care to children in the operating room, Dr. Brill and the surgeons and nurses use the “timeout” strategy to ensure that patients are getting the correct procedures. “Before we get started, all of the operating team members have to stop what they’re doing and identify the patient and the nature of the procedure involved to make sure that there is no chance for error,” she says.

Ways to improve communication among the department’s personnel are also being explored. Efforts focus on improving communication between nurses and residents as responsibility for patients is passed during shift changes, and on improving the transmission of critical information when a patient is transferred from one unit to another.

Dr. Mir is spearheading the effort to improve the error-reporting system so that near-mistakes and unreported errors are incorporated. “If the reporting system is too cumbersome, a lot of the near misses are not going to be caught, making it more difficult to understand and address the problems,” she explains.

Under Dr. Mir’s leadership, the Department of Pediatrics is also implementing simulation training for pediatric residents and nurses. Utilizing actors and equipment to simulate real-time critical scenarios, the simulations enable house staff to practice crisis resource management and team skills under stressful situations.

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