Patient Safety Lapses In Children's Care Are Prevalent, Drive Up National Health Care Costs

Johns Hopkins Medicine
Monday, 7 June 2004

Patient safety problems for hospitalized children occur frequently and with substantial impact on the children, as well as on the health care industry, according to a study by researchers at Johns Hopkins Children's Center and the Agency for Healthcare Research and Quality (AHRQ).

The research, the first to examine the impact of pediatric medical errors in terms of risk of in-hospital death, excess length of stay in the hospital, and excess charges, found that lapses in patient safety occurred most frequently among newborns and indigent children. The overall rate of medical errors was more than 100 for every 10,000 hospital discharges among 16 of the 20 most common patient safety events. Almost all incidents were associated with significant and substantial increases in hospital length of stay, charges or risk of death.

"This is the first analysis of the national impact of patient safety issues for hospitalized children, and it shows the enormous burden of the problem," said lead study author Marlene Miller, M.D., M.Sc., director of Quality and Safety Initiatives at the Johns Hopkins Children's Center. "It is concerning that so many pediatric patient safety events occurred in the very young and those on Medicaid insurance -- some of the most vulnerable hospitalized children."

She estimates that patient safety events led to over 4,000 deaths and incurred more than $1 billion in excess charges for hospitalized children in the year 2000.

In the study, published in the June issue of the journal Pediatrics, Miller and colleagues analyzed 5.7 million hospital discharge records from the year 2000 for children 19 and younger from 27 states using the AHRQ's established Patient Safety Indicators (PSIs), a set of algorithms used to help identify possible medical injuries occurring during hospitalization. They looked at 20 types of patient safety events, including birth and obstetric trauma, infections resulting from medical care and failure to revive a patient. Patient cases were divided by age (0 to 30 days, 31 to 365 days, 1 to 4 years, 5 to 9 years, 10 to 14 years and 15 to 18 years), gender and primary insurer.

The research team examined the rates of each patient safety event, the relationship between patient safety events and patient and hospital characteristics, and the impact of patient safety events on length of stay, charges and in-hospital death.

The overall number of patient safety events was more than 100 per 10,000 discharges for 16 of the 20 studied categories. The number of events per 10,000 discharges ranged from less than one for in-hospital postoperative hip fracture and transfusion reactions, to highs of 68 (birth trauma), 103 (postoperative sepsis), 703 (failure to revive), 1,072 (obstetric trauma without vaginal instruments) and 2,152 (obstetric trauma with vaginal instruments). Obstetric events refer to those experienced by teenaged mothers.

The youngest hospitalized children (0 to 30 days and 31 to 365 days) were consistently and significantly more likely than older children to experience patient safety events. Children aged one month or younger were about six times more likely to have postoperative sepsis or postoperative
hemorrhage, and about four times more likely to have technical difficulty with medical care and infection as a result of medical care, than those aged 1 to 4 years. Those aged one month to one year were up to two times more likely to experience these events than older children.

The team also found that children with Medicaid as their primary insurer were significantly more likely than children with private insurance to experience death, infections as a result of medical care, postoperative respiratory failure and postoperative sepsis.

Other findings of the study include:

• Birth trauma was significantly less likely to occur at teaching institutions compared with institutions that did not employ residents.
• Birth trauma was more likely to occur at institutions with lower nursing expertise.
• Nearly all patient safety events produced significant increases in hospital length of stay, up to highs of 26 extra days for postoperative sepsis and 30 extra days for infections resulting from medical care.
• All patient safety events led to excess hospital charges of $30,000 to $140,000 per case.
• All patient safety events were associated with significant increases in in-hospital death. Those with postoperative sepsis were at 11 times higher risk of dying, those with postoperative physiologic/metabolic problems were nearly 46 times more likely to die, and those with postoperative respiratory failure were nearly 77 times more likely to die than those who did not experience patient safety events.

The research was funded by the AHRQ. Chunliu Zhan, M.D., M.P.H., of the AHRQ was co-author.

For more information, or to contact Johns Hopkins Medicine, see their website at: www.hopkinsmedicine.org