Patient Safety Problems in Adolescent Medical Care

Patient Safety Problems in Adolescent Medical Care Donna M. Woods Ph.D. Eric Thomas MD MPH Edward Ogata MD, MM Jane L. Holl MD, MPH IHSRPS Feinberg School of Medicine Institute for Health Services Research & Policy Studies Background Medical errors and related injuries have become an important focus in health care  Limited understanding of these issues in children  No previous patient safety studies focused on adolescents  Background  Adolescents unique position in health care  Neither child nor adult  Receive care from Pediatricians, FP, Ob/Gyn, Internal Medicine  Laws governing confidentiality and majority vary by state Study Aim  To improve the understanding of the:  incidence,  nature,  types,  potential causes, and  possible solutions for patient safety problems in adolescent medical care. Methods - Multi-method design Study A: Quantitative population-based study using the Colorado and Utah Medical Practice Study data  Study B: Qualitative Critical Incident Analysis  Definitions  Adverse event: Injury caused by medical intervention or management, rather than the disease process, which either prolonged the hospital stay or caused disability at discharge.  Preventable adverse event: Injury caused by medical intervention or management (rather than the disease process) which either prolonged hospital stay or caused disability at discharge, where there was enough information currently available to have prevented the event using currently accepted practices.  Patient safety event/Critical incident: Medical care situations in which something did not go quite right, something did not go as planned in the process of medical care Study A - Methods  Study A: Quantitative population-based design to estimate incidence of adverse events and preventable adverse events Stratified random sample of hospitals (none refused)  Random sample of discharges within participating hospitals  Study A - Methods  Determination of Adverse Event and Preventable Adverse Event cases  2 level retrospective chart review (nurses then MD’s) using 18 specific criteria  Physicians determined adverse events based on a 6 point scale with threshold of 4 for determination  Physicians determined the level of harm  Investigators determined preventability based on 6 point scale (threshold of 4) Results Study A Rate per 100 Discharges of Hospital-based Adverse Events and Preventable Adverse Events in Children Age Group Adverse Events Preventable Adverse (years) Rate (CI 95%) Events Rate (CI 95%) 0 – 0.99 0.63 (0.43 - 0.83) 0.53 (0.33 - 0.73) 1 – 12.99 0.92 (0.62 -1.22) 0.22 (0.12 - 0.32) 13 – 20.99 3.41 (3.36 -3.46) 0.95 (0.65 - 1.25) Study B - Methods  Study B: Critical Incident Analysis technique a qualitative method for categorizing observational reports of critical incidents  Established in aviation  Increasingly applied in patient safety Study B - Methods  Data Collection  Audio-taped transcribed interviews with clinicians (physicians, nurses, pharmacists)  Data were classified using a triangulated transcript-based analysis (3 independent reviewers) Study B - Methods  Data  were classified into the following- Problem Type  Domain of Medicine  Child Specific Factors  Latent Conditions  Preventive Measures Results - Study B 35 clinician interviews  122 critical incidents  157 independent problems  31 problems in adolescent medical care  Harm ranged from no harm to death  Harm Scale           None Emotional Insignificant Injury Minor Temporary Major Temporary Minor Permanent Significant Permanent Major Permanent Grave Death Problem Types Tech/Equip Malfunction Problematic Execution Problematic Decision Problem Type Problematic Execution Problematic Communication Problematic Decision Tech/Equip Malfunction Problematic Communication Problematic Execution Problematic Decision Problematic Communication Technical/Mechanical Malfunction Total Harm (Mean) 2.0 4.6 3.3 1.0 2.8 Harm scale: 1 (emotional harm) – 9 (death). Domains of Medicine Domain of Medicine Medication Surgical and nonsurgical procedures Diagnostics Communication with patient or family Monitoring Other medical treatment Total Harm* (Mean) 1.3 3.5 4.6 3.0 Monitoring Medication Communication Diagnostics Procedures 2.3 1.6 2.8 Medication Procedures Diagnostics Communication Monitoring Harm scale: 1 (emotional harm) – 9 (death). Contributing Adolescent Oriented Child Specific Factors Physical Characteristic Minor Status Cognitive Social Emotional Development Physical Characteristic Physiological Development Cognitive Social Emotional Development Minor Status Physiological Development Child Specific Factors (CSF) Physical Characteristics Physiological Development Cognitive Social Emotional Development Minor Legal Status Total Adolescent CSFs Harm* (Mean) 3.3 1.8 3.7 3.7 3.0 Latent Conditions All Children Staffing Structure Adolescents Staffing Structure Error Prone Systems Culture Error Prone Systems Culture Structure Staffing Culture Error Prone Systems Error Prone Systems Culture Structure Staffing Problems in Adolescent Medical Care  Discomfort with adolescents, not described with other age groups contributed to 17% of the described problems Clinician Recommended Preventive Measures 30 25 20 15 10 5 Add Policies 0 16.2 29.7 Training Improved Communication Staffing Resources 13.5 10.8 10.8 8.1 8.1 Improved Equipment Systems Improved Design Use Existing Policies Limitations 2 different studies  Different populations  Different methodologies  Different contexts  Clinician judgment and perspective  Medical chart completeness  Clinician memory of specific details  Conclusions     Adolescents have the highest adverse event rate among children Preventable adverse event rate is significantly higher than children aged 1 - 12 years Over half of patient safety problems had a contributing child specific factor related to adolescents Highest levels of harm associated with diagnostics, and problematic clinical decisionmaking Implications  Patient safety solutions in adolescent medical care should: Address specific characteristics of adolescent patients  Address culture and systems in the context of adolescent medical care  Add components of adolescent medicine to general medical training for all clinicians  Methods - Study B  Constant Comparative Method Review all the incidents  Select a few and begin the formulating meaning  Continue with remaining reports and develop preliminary categories  Code data by categories and refine as needed and develop overarching categories  Deductive review for consistency and parallelism of categories  Complete coding of data and perform analysis  Example Medication  Prescription of pill form switched to liquid leading to ineffective levels of medication  Communication  Disclosing HIV status and sexual orientation despite the law providing confidentiality  Example  Development  “There was a girl who came in with a history of sore throat, She was a teen-ager, so we just didn’t recognize that she was as sick as she was because they labeled her a teenager….” Disclosing protected information to parents  Minor Status  Categories  Problem Types  Problematic Decision  Problematic Execution  Problematic Communication  Tech/Mechanical Malfunction  Child Specific Factors  Physical Characteristics  Development   Physiological Cognitive Social Emotional  Minor Legal Status