Quality of Care/Patient Safety

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To improve quality of care and patient safety, researchers are developing quality measures, analyzing medical injuries, and assessing the usefulness of diverse strategies to enhance care.

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Children do not benefit as much as adults from hospital computer order entry systems.

Researchers collected data on 627 children hospitalized in a pediatric surgical or medical unit, pediatric intensive care unit, or a neonatal intensive care unit either before or after implementation of a commercial computerized physician order entry system (CPOE). Medication error rates were not significantly different after implementation of CPOE, even though studies have shown reductions of up to 55 percent in serious medication errors in adults following introduction of CPOE. The researchers note that the system they evaluated was not optimally designed to prevent common pediatric medication errors, such as mistakes in the use of weight-based dosing calculations. Walsh, Landrigan, Adams, et al., Pediatrics 121(3), 2008; online at www.pediatrics.org (AHRQ Grant HS13333).

Voluntary reporting and other strategies identify adverse drug events in children.

The best approach for detecting pediatric adverse drug events (ADEs) involves use of voluntary reporting in tandem with targeted chart review and computerized surveillance, according to researchers. They examined all ADEs detected by one hospital's computerized surveillance and safety reporting systems over a 1-year period. Of the 849 errors entered into the reporting system, 93 caused patient harm. The two methods of detecting ADEs did not duplicate each other but were complementary. Ferranti, Horvath, Cozart, et al., Pediatrics 121, 2008; online at www.pediatrics.org (AHRQ Grant HS14882).

Multiple prescriptions are linked to preventable drug reactions in children.

Children's medications come in tablets, drops, and liquids, and in many cases, the dose depends on the child's weight. Children who are prescribed multiple drugs are at increased risk for experiencing a preventable adverse drug event (ADE). Researchers studied data on 1,689 children who were seen from July 2002 to April 2003 at six sites in Boston and received a total of 2,155 prescriptions. Of these, there were 283 ADEs in 242 children (14 percent), and 70 percent of the ADEs occurred when parents were administering the medication. Fifty-seven of the ADEs were preventable. Zandieh, Goldmann, Keohane, et al., J Pediatr 152:225-231, 2008 (AHRQ Grant HS11534).

Pediatricians don't always pursue answers to questions that arise during medical visits.

Researchers observed 890 visits with 35 general pediatricians; 19 percent of the visits involved children with special health care needs. Nearly 20 percent of the visits prompted unanswered questions, of which 60 percent were deemed important or very important by physicians. Physicians said they intended to purse answers to half of the questions but actually only pursued answers for about 28 percent of questions. They cited lack of time and inadequate information resources as barriers to getting the information they needed to answer the questions. Unanswered questions arose nearly twice as often for children with special health care needs as for other children. Nolin, Sharp, and Firth, Ambul Pediatr 7(5):396-400, 2007 (AHRQ Grant HS11826).

Pediatricians appear less likely than other physicians to exhibit race bias or harbor stereotypes.

Researchers surveyed academic pediatricians about their implicit and explicit racial attitudes and stereotypes using a specially designed test. To measure quality of care, subjects were asked how they would treat patients using four pediatric vignettes (pain control, urinary tract infection, ADHD, and asthma). Each participant was given two black and two white patients; most of the pediatricians were white, and 93 percent were American-born. The majority of pediatricians reported no difference in feelings toward racial groups; there was a much smaller implicit preference for whites relative to blacks than found with other physicians. More than 1 million individuals have taken the race/attitude test. Sabin, Rivara, and Greenwald, Med Care 46(7):678-685, 2008 (AHRQ Grant HS15760).

Distance-based quality improvement approach shows promise for improving pediatric immunization rates.

Researchers randomly assigned 29 pediatric research network-based practices into year-long paper-based education or distance-based QI groups to examine differences in immunization rates at the end of the year. Baseline immunization rates of 88 percent or less for children aged 8 to 15 months were similar for the two groups. Practices in the paper-based group received only mailed educational materials. Those in the distance-based group participated in monthly conference calls, logged into e-mail discussion groups, and made use of a Web site that shares best practices and other information. Pediatricians in the QI group boosted their immunization rates by 4.9 percent compared with 0.8 percent for the paper-based education group. Slora, Steffes, Harris, et al., Clin Pediatr 47(1):25-36, 2008 (AHRQ Grant HS13512).

Parents of Medicaid-insured children may have limited access to health information.

Inappropriate use of antibiotics contributes to antibiotic-resistant infections, yet some parents continue to pressure doctors into prescribing antibiotics for children when they are not indicated (e.g., for viral infections). Researchers conducted a 3-year, educational intervention directed at parents of children ages 6 and younger in 16 Massachusetts communities (eight intervention, eight control). Parental knowledge about antibiotics improved with time in both intervention and control groups, particularly among parents of Medicaid-insured children. This may reflect limited access of parents of Medicaid-insured children to health-related information from other sources. Huang, Rifas-Shiman, Kleinman, et al., Pediatrics 119:698-706, 2007 (AHRQ Grant HS10247).

Family-centered, high quality primary care is linked to fewer nonurgent ED visits by children.

Researchers used data from the 2000-2001 and 2001-2002 Medical Expenditure Panel Survey to examine parental reports on the quality of primary care with respect to family-centeredness, timeliness, and access to care. Of the nearly 9,000 children included in the study, parents rated access to care (88 percent), family-centeredness (70 percent), and timeliness (56 percent) as high quality. Parental report of family-centered care was associated with 49 percent fewer ED visits for children age 2 and younger; greater access was associated with 44 percent fewer nonurgent ED visits for children ages 3 to 11 and 56 percent fewer visits for children ages 12 and older. There was no association between timeliness and nonurgent ED use. Brousseau, Hoffmann, Nattinger, et al., Pediatrics 119(6):1131-1138, 2007 (AHRQ Grant HS15482).

Study documents little interaction between doctors and parents/patients during pediatric visits.

Most parents and children accept the doctor's treatment recommendations without discussion, even though studies have shown that patient participation results in better outcomes, according to this study. The researchers reviewed videotapes of 101 visits to 15 physicians for pediatric complaints and found that 65 percent of parents and children accepted the doctor's recommendation with no discussion of their preferences. They also found that parents and children were less inclined to stay quiet during longer visits, and discussion of treatment options occurred most often when the doctor and patient were female and the doctor had been practicing for several years. Cox, Smith, and Brown, Pediatrics 120, 2007; online at www.pediatrics.org (AHRQ Grant HS13183).

Medication errors were made during half of the pediatric encounters at four rural EDs.

Researchers identified the incidence, nature, and consequences of medication errors among all critically ill children treated at four rural EDs in California between January 2000 and June 2003. They found that medication errors occurred during the care of half of the children. Among the 69 children with medication errors, 16 percent involved errors that had the potential to cause harm, although none of the errors caused significant harm. Fifteen percent of the errors were due to erroneous physician orders (e.g., wrong dose, wrong medication, incorrect route, etc.). Marcin, Dharmar, Cho, et al., Ann Emerg Med 50(4):361-367, 2007 (AHRQ Grant HS13179).

Most pediatricians endorse reporting errors to hospitals and disclosing them to parents.

Researchers surveyed 439 pediatric attending physicians and 118 residents and found that most of them had been involved in a medical error. The pediatricians indicated their willingness to report errors to hospitals and disclose errors to patients' families, but they believe current reporting systems are inadequate and struggle with error disclosure. The researchers conclude that improving error reporting systems and encouraging physicians to report near misses, as well as providing training in error disclosure, could help prevent future errors and increase patient trust. Garbutt, Brownstein, Klein, et al., Arch Pediatr Adolesc Med 161:179-185, 2007 (AHRQ Grants HS11890, HS14020).

Many children treated at pediatric hospitals receive at least one off-label medication.

Many medications prescribed for children have not been formally studied in children, and most are not labeled for use in children. However, this study found that children treated at pediatric hospitals commonly receive at least one medication off-label, i.e., not approved by the FDA for their age. The researchers examined use of 90 drugs among children treated at 31 major children's hospitals across the Nation. At least one of the drugs was used off-label in more than three-fourths of children discharged from pediatric hospitals during the study. Children who were more seriously ill and had longer hospital stays were more likely to receive off-label drugs than other patients, as were patients who were older than 28 days, underwent surgery, or died in the hospital. Shah, Hall, Goodman, et al., Arch Pediatr Adolesc Med 161:282-290, 2007 (AHRQ Grant HS14009).

Doctor/patient interaction is enhanced when the child is accompanied by the mother and/or the child is female.

Children who actively participate in their care tend to manage their chronic disease better and reduce their use of health care; also, when children and parents actively participate in conversations during visits with the pediatrician, more information is exchanged and the patient/provider relationship is enhanced. In this study, girls did twice as much relationship-building as boys, and their pediatricians gathered 34 percent more information. Also, when the father accompanied the child instead of the mother, relationship-building was reduced 76 percent, and information given by the physician was reduced 14 percent. The sex of the physician had no significant effect on participation. For this study, the researchers examined videotapes of 100 visits to pediatricians. Cox, Smith, Brown, and Fitzpatrick, Patient Educ Counsel 65:320-328, 2007 (AHRQ Grant HS13183).

Parents of children with cancer want as much information as possible about their child's prognosis.

Researchers surveyed 194 parents whose children were treated for cancer and their physicians at a Boston medical center. The majority of parents wanted as much information as possible about their child's prognosis even though they found it upsetting. One-third of parents said the oncologist did not initiate a discussion about prognosis, and this limited information may inappropriately alter the choices parents make about treatment. The researchers conclude that parents have the capacity to hope for a cure while simultaneously preparing for the possibility of death, but they need information to do so. Mack, Wolfe, Grier, et al., J Clin Oncol 24(33):5265-5270, 2006 (AHRQ Grant HS00063).

Researchers examine ways to improve the quality of pediatric critical care.

The Institute of Medicine's six aims for improving quality of care provide a useful framework to advance quality of care in pediatric intensive care. In this article, the authors discuss the relevance of the six aims, which are: safety, effectiveness, equity, timeliness, patient-centeredness, and efficiency. Slonim and Pollack, Pediatr Crit Care Med 6(3):264-269, 2005 (AHRQ Grant HS14009).

Potential medication dosing errors occur often during outpatient pediatric care.

According to these researchers, medication doses were incorrectly cited in about one in seven (15 percent) new prescriptions written during children's outpatient visits. Slightly more than half of these incorrect dosages involved potential overdoses. Young and medically complex children, who are most vulnerable to potentially serious adverse drug events, were most likely to be prescribed potential drug overdoses. These findings were based on an analysis of pharmacy data from three HMOs for 1,933 children. McPhillips, Stille, Smith, et al., J Pediatr 147:761-767, 2005 (AHRQ Grants HS10391 and HS11843; AHRQ contract 290-00-0015).

Real-time safety audits can detect a broad range of errors in neonatal intensive care units.

The researchers implemented a real-time audit system, including a 36-item patient safety checklist, in a 20-bed NICU in Vermont. The checklist included errors associated with delays in care, equipment failure, diagnostic lab and radiology exams, information transfer, and noncompliance with hospital policy. A research nurse used the checklist to perform safety audits during and after morning work rounds three times a week. The audits detected 338 errors during the 5-week study period, including unlabeled medication at the patient's bedside, missing or inappropriately placed ID bands, improper alarm settings on pulse oximeters, ineffective communication, and delays in care. Errors usually were detected at the patient's bedside. Ursprung, Gray, Edwards, et al., Qual Safety Health Care 14:284-289, 2005 (AHRQ Grant HS11583).

Treatment recommendations published during physicians' residencies impact their future clinical practice.

Using clinical vignettes, researchers found that pediatricians recommended sepsis workups 82 percent of the time, and family physicians recommended them 68 percent of the time, for febrile infants less than 3 months of age. These recommendations were more common among pediatricians who completed residency from 1975 to 1980 and family physicians who completed residency from 1981 to 1987, when specialty-specific journals published recommendations for sepsis workups of febrile infants. Cox, Smith, and Bartell, Eval Health Prof 28(3):328-348, 2005 (AHRQ Grant HS13183).

Nurses have an important role in preventing medication errors in hospitalized children.

These researchers suggest several practical steps that nurses should take to improve pediatric medication safety in the hospital. Examples include: reporting medication errors, double-checking drugs prescribed for off-label use, confirming patient information, minimizing distractions during medication administration, communicating with parents and involving them in patient care, and many others. Hughes and Edgerton, Am J Nurs 105(5):36-42, 2005 (AHRQ Publication No. 05-R052)* (Intramural).

National reports focus on health care quality and disparities.

AHRQ has released the 2007 national reports on health care quality and disparities. These reports, which are prepared by AHRQ annually, provide measures of quality and disparities for the U.S. population, including children and adolescents. The reports cover four key areas of health care—effectiveness, safety, timeliness, and patient centeredness—and present data on several clinical conditions, including cancer and respiratory diseases. National Healthcare Quality Report (AHRQ Publication No. 08-0040) and National Healthcare Disparities Report (AHRQ Publication No. 08-0041)* (Intramural).

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Other Research

Results from the Healthy Steps for Young Children program appear promising.

Even though the Healthy Steps for Young Children (HS) program ended at 3 years, its impact was sustained among 5-year-old children, according to this study. A smaller percentage of HS parents slapped their child in the face or spanked their child with an object, compared with parents in a non-HS group. Also, HS parents were more likely to negotiate with their child, ignore misbehavior, and encourage children to read and use car seat restraints than parents in the non-HS group. Minkovitz, Strobino, Mistry, et al., Pediatrics 120(3), 2007; online at www.pediatrics.org (AHRQ Grant HS13086).

Behavioral problems and reduced social skills linked to heavy TV viewing by young children.

This study found that one in five children 2.5 to 5.5 years of age watched TV more than 2 hours a day, and more than 40 percent of 5-year-old children had TVs in their bedrooms. Timing of TV exposure had varying impact: heavy viewing by 2-year-olds was associated with later behavioral problems, while 5-year-olds with current heavy TV viewing had fewer social skills than their peers without such heavy viewing. Mistry, Minkovitz, Strobino, and Borzekowski, Pediatrics 120(4):762-769, 2007 (AHRQ Grant HS13086).

Pediatric autopsies shed light on cause of death in more than half of cases.

Researchers studied autopsy records of 100 children ages 1 to 24 who died at the Children's Hospital of Philadelphia in 2003 and 2004. In more than half of the cases, autopsies were able to clarify why the child died and gave parents a clearer explanation for their child's death. Having this information enabled 20 percent of the parents to make more informed decisions about having future children. The hospital also benefitted from autopsy results, especially in cardiac cases or when a metabolic or genetic diagnosis was difficult. Feinstein, Ernst, Ganesh, and Feudtner, Arch Pediatr Adolesc Med 161(12):1190-1196 (AHRQ Grant HS00002).

Study shows that differences in wording can have significant effects on parental responses to survey instruments.

Researchers compared responses of parents of 66 children with cerebral palsy to three instruments commonly used to measure function and quality of life for pediatric orthopedic patients to determine consistency in answering the same or similar questions, the impact of variations in wording, and the effects of survey language (English or Spanish). Of the eight questions that overlapped, six had poor to fair agreement in parental responses; only the two questions with nearly exact wording had similar parental responses. Wren, Sheng, Hara, et al., J Pediatr Orthopaed 27(2):233-240, 2007 (AHRQ Grant HS14169).

Visits to pediatric practice-based research networks appear to be comparable to national pediatric outpatient visits.

Practice-based research networks—in which multiple primary care practices study similar clinical problems—have become an important feature of primary care research, yet the generalizability of their patient samples has been called into question. According to this study, there is no significant difference among the top five patient visit diagnoses between data from the Pediatric Research in Office Settings Network and the National Ambulatory Medical Care Survey. Thus, the network's patient population is reasonably representative of patients who are seen in other office-based pediatric primary care practices. Slora, Thoma, Wasserman, et al., Pediatrics 118(2), 2006; online at www.pediatrics.org (AHRQ Grant HS13512).

Many evidence-based interventions shown to improve children's health are not being used in clinical practice.

This paper describes the processes used and outcomes generated from the first Evidence-Based Practice Leadership Summit focused on children and adolescents. One outcome of the summit was launching of the new National Consortium for Pediatric and Adolescent Evidence-Based Practice. Examples of future initiatives include the development of evidence-based clinical practice guidelines, the use of mentors to improve the care and health of children and adolescents, and new tools and resources to further evidence-based practice. Melnyk, Fineout-Overhold, Hockenberry, et al., Pediatr Nurs 33(6):525-529, 2007 (AHRQ Grant HS11675).

AHRQ's KID database facilitates child health services research.

In August 2001, AHRQ unveiled the Kids' Inpatient Database (KID), the Nation's first all-children's hospital care research database. It was developed for use in making national and regional estimates of children's treatment, including surgery and other procedures, and for estimating treatment outcomes and hospital charges. The database includes information on the hospital care of children from birth through age 18, regardless of insurance status. The KID contains information on the inpatient stays of about 1.9 million children at over 2,500 hospitals across the country in 2000. KID is a component of AHRQ's Healthcare Cost and Utilization Project (HCUP).

For more information, go to the AHRQ Web site at http://www.ahrq.gov/data/hcup/.

Pediatric disaster preparedness resource now available.

Children have increased vulnerability to injury from catastrophic events because of their unique anatomic, physiologic, immunologic, and developmental characteristics. This new resource, which was prepared for AHRQ by the American Academy of Pediatrics, can assist in the development of local, State, regional, and Federal emergency response plans that recognize and address these differences. The resource is intended to increase awareness and encourage collaboration among pediatricians, State and local emergency response planners, health care systems, and others involved in planning and response efforts for natural disasters and terrorism. Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians (AHRQ Publication Nos. 06-0056, full report, and 06-0048, summary).*

These publications are also available online at http://www.ahrq.gov/research/pedprep/resource.htm (Purchase order 05R000190).

Children's use of motor vehicle restraints may be linked to parental use of seat belts and mother's psychological distress.

Researchers analyzed data on more than 6,200 children aged infant to 17 years and found that children whose mothers have emotional problems and/or don't use seat belts are less likely than other children to be restrained by car seats or seat belts themselves. Older children were especially likely to forgo seat belts if their mothers did. More than 35 percent of children were low users of restraints if their mothers also reported low use, compared with 6.1 percent of children whose mothers buckled-up every time or most of the time. Children were less likely to be restrained if their mother was older, black, or less educated or if they lived with a single parent, in a family of four or more members, in poverty, or in a rural area. Witt, Fortuna, Wu, et al., Ambulatory Pediatr 6:145-151, 2006 (AHRQ Grant T32 HS00063).

Age is a better marker than height and weight for assessing the risk of air bag deployment.

The government requires warnings on motor vehicles that children aged 12 and younger can be seriously injured or killed by an air bag. However, this study found that the risk of serious air-bag-related injury may extend to age 14 when children are seated in the right front passenger seat in vehicles equipped with air bags. Researchers analyzed data for nearly 3,800 children aged 1 month to 18 years and found that children aged 15 to 18 years who were involved in frontal collisions were 81 percent less likely than younger children to be injured when an air bag deployed. Changes in body composition and bone mass associated with the onset of puberty (typically age 11 for girls and age 13 for boys) may play a role in susceptibility to injury from air bags, note the researchers. Newgard and Lewis, Pediatrics 115(6):1579-1585, 2005 (AHRQ Grant F32 HS00148).

U.S. children use electronic media an average of more than 4 hours a day.

Researchers conducted a survey of parents during well-child office visits to assess children's media use and parental oversight and control of media use. Children in this study were using electronic media (e.g., TV, video games, and computers) an average of 4 hours a day, or twice the recommended limit of 2 hours. More than half of parents used some type of strategy to control and inform their children's use of electronic media. About 23 percent used a restrictive approach, and 22 percent used an instructive approach, while some parents used multiple approaches. Only 7 percent of parents allowed unlimited media use and engaged in no mediation strategy. Barkin, Ip, Richardson, et al., Arch Pediatr Adolesc Med 160:395-401, 2006 (AHRQ Grant HS10913).

Anthrax in children is difficult to detect and treat.

According to an AHRQ evidence report, difficulties in diagnosing anthrax in children may lead to dangerous delays in treatment for this often deadly infection. Symptoms of pediatric anthrax infection can be easily confused with those of more common illnesses. For example, the symptoms of inhalational anthrax are similar to those of influenza. Also, there is little evidence about the effectiveness in children of interventions currently recommended for adults. Pediatric Anthrax: Implications for Bioterrorism Preparedness, Evidence Report/Technology Assessment No. 141 (AHRQ Publication No. 06-E013)* (contract 290-02-0017).

Home routines in minority families may impede the development and future school success of children.

According to this study, black and Hispanic children younger than age 3 experience multiple disparities in home routines, safety measures, and educational practices/resources that could impede their healthy development and future school success. For example, minority parents were less likely than white parents to install stair gates or cabinet safety locks or to lower the temperature setting on hot water heaters to prevent scalding. Minority parents also were much less likely than white parents to read to their children daily, and they had fewer children's books in the home. Flores, Tomany-Korman, and Olson, Arch Pediatr Adolesc Med 159:158-165, 2005 (AHRQ Grant HS11305).

DVD shows clinicians how to care for children exposed to chemicals used in bioterrorism.

This 27-minute training DVD provides a step-by-step demonstration of the decontamination process and instructs clinicians about the nuances of treating infants and children. A free, single copy of the DVD, The Decontamination of Children, is available (AHRQ Product No. 05-0036-DVD)* (AHRQ contract 290-00-0020).

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AHRQ Publication No. 09-PB001
(Replaces AHRQ Publication No. 07-P007)
Current as of December 2008

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Internet Citation:

Child Health Research Findings, Program Brief. AHRQ Publication No. 09-PB001, December 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/childfind/

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