DC Child Accident & Safety Blog

The American Academy of Pediatrics (AAP) has revised its patient safety guidelines to reduce unintended harm to children by the healthcare system.

Noting that national awareness of patient safety risks has grown in this decade, Marlene Miller, MD, and AAP colleagues write in the June issue of Pediatrics that “the depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to uncover a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification.”

As technology evolves and medical advances become increasingly complex, the risk of causing unintentional medical harm has also increased, they write, pointing to studies that show seven failures to prevent a clinically important deterioration per 100 hospitalized children, 100 prescribing errors per 1000 children seen in an emergency room, and three preventable adverse drug events per 100 children seen in pediatric practices.

"The field of pediatric patient safety has matured much in recent years; there are now more robust epidemiology of errors for children, a deep understanding of the concept and measurement of a culture of safety, clear guidance on key elements of patient-safety solutions and introduction of successful pediatric patient-safety solutions," the article says.

"Nonetheless, continued work is needed to infuse these data and concepts into everyday pediatric practice for all clinicians, and special attention should be paid to the training of new clinicians to ensure that the future workforce can exercise all the tenets of pediatric patient safety as part of their everyday work life.

The new AAP patient safety recommendations aim to:

Expand efforts to educate clinicians, ensuring that they can all identify pediatric patient-safety issues and know how to improve them individually and within healthcare systems.

Create a safety culture by challenging all organizations, including small practices, to implement a pediatric patient safety plan that informs, supports and educates using appropriate local examples.

Develop patient-safety metrics for the ambulatory settings, where most children in the U.S. primarily interact with the healthcare system (though most patient safety work to date has been in hospitals).

Develop and support broad-scale pediatric error-reporting systems and analysis of reported events.

Comply with proven best practices for improving pediatric patient safety to enhance pediatric healthcare outcomes.

Target drug safety by advocating for the development of effective and safe pediatric medications and formulations and for withdrawal of medications with unfavorable risk/benefit ratios.

Educate clinicians on strategies to reduce medication errors by ensuring that they maintain access to and proficiency in the use of a comprehensive and current pharmaceutical knowledge base.

Source: Medscape

You can read the full text of the AAP statement here.

Nearly half the children treated as inpatients for psychotic and mood disorders are given atypical antipsychotics, a new single-center study reports. About 44% of these young patients with a variety of conditions, ranging from psychosis to various mood and anxiety disorders, were treated with either first- or second-generation versions of the drugs, according to the study, which was recently presented at the American Psychiatric Association meeting in Honolulu.

To determine the prevalence of antipsychotic use and associated clinical characteristics - and to compare current use with past use - the researchers looked at 3,851 inpatients ages 5 to 17 who were seen at their facility between January 2000 and June 2010 for various diagnoses, including psychosis, behavioral disorder, depression, post-traumatic stress disorder (PTSD) and anxiety.

They found that antipsychotics were prescribed for 44.3% of patients, and that a higher proportion of those scrips were written for children (ages 5 to 12) than adolescents (ages 13 to 17) - 51.7% versus 41.7%.

Atypical prescribing varied by diagnosis, with prescriptions written for:

• 76% of psychosis patients (including schizophrenia and bipolar disorder)

• 45% of behavioral patients (including ADHD, panic disorder, and social phobia)

• 24% of depression patients

• 46% of PTSD patients

• 31% of anxiety patients

• 20% of patients with other diagnoses

The study authors expected atypical use to be most common in people with psychotic systems, but were surprised to see such high use of atypicals in behavioral diagnoses. The likely explanation is that the study focused on inpatients, who may exhibit more severe behavioral issues than outpatients.

Atypical antipsychotics were also more likely to be prescribed to males, nonwhites and those with a longer length of stay. Surprisingly, the general use of atypicals decreased over the study period, from 47% between 2001 and 2003 to 43.5% between 2006 to 2010.

The study was limited because it was done at a single center and because it lacked follow-up after discharge, and the study authors called for further study and the need for comparison with other institutions.

Source: Medpage Today

Study reference: Stevens M, et al "Current prescribing practices: antipsychotic use in children and adolescents" APA 2011; Abstract 12-41

Prompted by a lack of consensus on who should get their tonsils removed and how it should be done, the American Academy of Otolaryngology–Head and Neck Surgery has issued the first-ever clinical guidelines for tonsillectomy in children in the U.S.

Child safety advocates have argued for years that tonsillectomy is done way too often. This exposes kids to risks of an operation they may not need -- mainly from anesthesia and bleeding. Because the tonsils are situated at the junction of several blood vessels, the procedure carries a relatively high risk of hemorrhage.)

For example, it's been known for decades that children’s health in areas with high rates of tonsillectomy is no better than in areas in which fewer tonsillectomies are performed.

But the operation still gets done for preventive or “prophylactic” reasons. As a result, tonsillectomy currently is the third most common surgery in U.S. children younger than 15 years, with more than 530,000 performed annually, primarily for recurrent throat infections and sleep-disordered breathing, despite the risks.

The guidelines provide evidence-based guidance in identifying children who may benefit from tonsillectomy. They also offer recommendations intended to optimize the "perioperative" management of children undergoing the procedure and provide guidance on how to improve counseling and education of parents of children who may be candidates for tonsillectomy and suggests ways to reduce inappropriate or unnecessary variations in care.

According to the new guidelines, the need for a tonsillectomy is determined by the frequency of a child’s sore throats. Tonsillectomy should be considered when a child has (a) seven sore throats in a single year; (b) five sore throats for 2 years running; or (c) three sore throats for 3 years running. To count for this purpose, each sore throat must be accompanied by a fever of at least 38.3C (101F), swollen lymph nodes in the neck, pus or blood draining from the tonsils, or documented infection with a bacteria called hemolytic streptococcus.

The guidelines also recommend:

Watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years.

Assessing the child with recurrent throat infection who does not meet the criteria above for modifying factors that may nonetheless favor tonsillectomy, which may include multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess.

Asking caregivers of children with sleep-disordered breathing and tonsil enlargement about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis and behavioral problems.

Counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing.

Counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management.

Advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain.

Self-monitoring by clinicians who perform tonsillectomy at least annually to determine their rate of primary and secondary posttonsillectomy hemorrhage.

Source: American Academy of Otolaryngology – Head and Neck Surgery