Stepping Up Pediatric Patient Safety (Chris Dckinson)
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Transcript of Stepping Up Pediatric Patient Safety (Chris Dckinson)
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CS Mott Children’s Hospital: Patient Safety Issues
Chris J. Dickinson, M.D.
Chief Medical Officer
Children’s & Women’s
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CS Mott Children’s Hospital
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CS Mott Children’s Hospital
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CS Mott Background - I
• Part of University of Michigan Health
• Single campus – Mott attached to adult University Hospital – Medical and Nursing Schools on same campus– School of Public Health across the street
• Located in Ann Arbor, Michigan – Population 116,000 without students– Population almost doubles on football Saturdays– 45 miles from Detroit
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CS Mott Facts - II
• 234 pediatric beds new building 5 years old – 128 acute care– 60 ICU– 46 neonatal ICU
• 20 OR’s – IR, MR/OR, 3 cardiac OR’s
• Emergency Department – 36 beds & 25,000 visits/yr
• Attached out-patient space with infusion area
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Background-III
• 50 women’s obstetric beds located in the Von Voigtlander Women’s Hospital – 9th floor same building
• NICU on 8th floor– 4,800 births/year– Useful for critically ill mothers or babies
• Exit procedures where the baby is delivered by c-section but placenta is not
• Baby then placed on ECMO and cord cut• Placenta delivered and maternal wound closed
– OB clinics and fetal diagnostic center adjacent
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Super Heroes
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Significanteventsorinjuries
SlideconceptadaptedfromJamesReason,ManagingtheRisksofOrganiza2onalAccidents,1997
SuperHeroesinMedSafety Joyce
Somepoten7alerrors:• Medica7onSelec7on• Concentra7on• Route• Interac7onorAllergy
Wri2ngasinglemedica2onorder
AnnuallyInMo@weadminister~1.2milliondrugdoses
Resident
Nurse Med Manager
Pharmacist
If together we are 99.9% accurate
3-4 errors reach the patient every day
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Root Cause Analysis of Med Errors
• Many medications used in pediatrics are not commercially available as liquids and must be compounded
• Prescribers have no control over the concentration of any compounded medication – Pharmacies can and do compound at many different
concentrations for a single drug– Problem when patients arrive from outside and
family says they give 1 tsp of med• There is no single “gold-standard” recipes for
compounding which can lead to: – Concentration errors– Stability concerns
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Compounded Meds
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Solution
• Standards developed
• Website created – mipedscompounds.org – Includes standards, recipes, references
•
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Pediatric Safety Issues
• Often similar to adult issues but there are significant differences – Children’s safety should be informed by but not
driven by adult issues
• There is a need for better pediatric specific quality metrics for children’s hospitals to focus on
• Children’s Hospitals will need to work together (Solutions for Patient Safety) – Share data and ideas