Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study

Background:

Limited data are available on adverse events among children admitted to hospital. The Canadian Paediatric Adverse Events Study was done to describe the epidemiology of adverse events among children in hospital in Canada.

Methods:

We performed a 2-stage medical record review at 8 academic pediatric centres and 14 community hospitals in Canada. We reviewed charts from patients admitted from April 2008 through March 2009, evenly distributed across 4 age groups (0 to 28 d; 29 to 365 d; > 1 to 5 yr and > 5 to 18 yr). In stage 1, nurses and health records personnel who had received training in the use of the Canadian Paediatric Trigger Tool reviewed medical records to detect triggers for possible adverse events. In stage 2, physicians reviewed the charts identified as having triggers and described the adverse events.

Results:

A total of 3669 children were admitted to hospital during the study period. The weighted rate of adverse events was 9.2%. Adverse events were more frequent in academic pediatric centres than in community hospitals (adjusted odds ratio [OR] 2.98, 95% confidence interval [CI] 1.65–5.39). The incidence of preventable adverse events was not significantly different between types of hospital, but nonpreventable adverse events were more common in academic pediatric centres (adjusted OR 4.39, 95% CI 2.08–9.27). Surgical events predominated overall and occurred more frequently in academic pediatric centres than in community hospitals (37.2% v. 21.5%, relative risk [RR] 1.7, 95% CI 1.0–3.1), whereas events associated with diagnostic errors were significantly less frequent (11.1% v. 23.1%, RR 0.5, 95% CI 0.2–0.9).

Interpretation:

More children have adverse events in academic pediatric centres than in community hospitals; however, adverse events in the former are less likely to be preventable. There are many opportunities to reduce harm affecting children in hospital in Canada, particularly related to surgery, intensive care and diagnostic error.Children are vulnerable to harm associated with medical care. Although there is a need to make health care safer,¹ transforming the system requires knowledge of the full scope and burden of health care–associated injury in pediatric medicine. Chart and administrative database reviews showing rates of adverse events of 3% or lower among children admitted to hospital^2–4 have been superseded by data from targeted studies using trigger tools to identify patient charts warranting review for adverse events.^5–7 Unfortunately, the absence of a comprehensive pediatric trigger tool has limited the understanding of the full burden of health care–associated harm.The Canadian Paediatric Trigger Tool was validated to identify adverse events in children admitted to hospital.⁸ Using this tool, we conducted the Canadian Paediatric Adverse Events Study to determine and compare the incidence, type, severity and preventability of adverse events among children admitted to academic pediatric centres with those admitted to community hospitals in Canada.     

Neonatal resuscitation in Canadian hospitals.

A survey of Canadian hospitals providing obstetric care was undertaken to assess preparation, protocols, training and staff availability for neonatal resuscitation. Of the 721 hospitals contacted 577 (80%) responded. The reported availability of written guidelines for resuscitation varied greatly, depending on hospital size and proximity to a tertiary care centre. Many hospitals, especially those with 300 births or fewer annually, reported that they depend on family physicians or nurses to start and to continue neonatal resuscitation. Approximately one third of the hospitals had written guidelines for summoning personnel for additional help, and one third used a list of maternal or fetal indications for the presence of a physician specifically for the care of the infant at birth. Of 200 hospitals 138 (69%) had to summon additional medical help from outside the institution, 60% at all times. A neonatal resuscitation team in which members'' roles were defined was established in 22% of the hospitals. Few hospitals held rehearsals for resuscitation. Nurses were permitted to perform intubation in 21 hospitals (4%), 7 of them in Alberta. National professional bodies should develop guidelines for training and skill maintenance, and hospitals should develop protocols for maintaining equipment and for neonatal resuscitation team activities, including regular practice. Training should be improved in family practice and obstetrics programs, and consideration should be given to training senior obstetric nurses and respiratory therapists in intubation of neonates.     

AIDS: medicolegal considerations for Canadian hospitals.

Given the increasing endemicity of human immunodeficiency virus (HIV), the agent implicated in the causation of acquired immune deficiency syndrome (AIDS), in numerous sizeable subgroups of society, hospitals can expect increasing exposure to the legal implications presented by patients with AIDS. This paper reviews the duty of care owed by hospitals, both directly, through contractual obligations, and indirectly, through the acts of their employees and private contractors, to patients with AIDS, other patients and the public. Owing to the absence of case law directly related to AIDS or to HIV antibody reactivity, inferences were drawn from precedents set with other infectious diseases. Recommendations are made in the areas of confidentiality, informed consent, standards of care and vicarious liability.     

Genetic analysis of return over feed in Canadian Holsteins

The objective of this study was to investigate genetic merit of return over feed (ROF), which is a herd profit index defined by CanWest Dairy Herd Improvement as a difference between milk income and feed cost. A multiple-trait (MT) model and random regression model (RRM) were used. The traits analyzed in MT were rearing cost and ROF of the first three lactations. In RRM, a cumulative ROF was fitted as function of age and rearing cost was treated as a correlated trait. Variance components were estimated within a Bayesian framework by Gibbs sampling using a subsample of data. Breeding values were then estimated for 3 041 078 animals using records of 1 951 893 cows. Estimates of heritability for rearing cost from MT and RRM were 0.23 and 0.22, respectively. ROF per lactation and cumulative ROF were negatively correlated with rearing cost. Estimates of heritability of ROF through the first, second and third lactation from MT were 0.27, 0.10 and 0.08, respectively. Estimates of heritability of ROF from RRM increased with age and ranged from 0.08 through 0.31. Estimated breeding values (EBVs) for ROF from MT and RRM were moderately correlated with official EBV for production traits and the Canadian selection index (Lifetime Profit Index). Herd life EBV had -0.07 and 0.19 correlations with EBVs for ROF from MT and RRM, respectively. From both MT and RRM, small favorable correlations were reported between EBVs for ROF and for bone quality and angularity, whereas low unfavorable correlations were reported with EBV for udder depth, front end and chest width. Majority of correlations between EBVs for ROF and for reproduction traits were near 0, with the exception of EBV for gestation length, calf size and calving ease, where small favorable correlations were reported. The ROF is a good indicator of cow profitability despite the fact that it is a simplified profit index that does not account for animal-specific health and reproductive cost. However, because ROF does not account for differences in heritabilities between components of profit, ROF is not recommended to be used for direct selection for profit.     

Physician retirement: a case for concern in Canadian hospitals.

Mandatory retirement is being challenged on the basis of age discrimination, and physicians are not divorced from this social trend. In January 1982 legal precedent was set by the Manitoba Court of Appeal concerning the retirement policy for physicians in Canada. Currently, Canadian hospital bylaws include clauses that require a change in membership status once a physician reaches 65 years of age. The main arguments in favour of this change include easier physician manpower management, ensured public safety and, in some instances, greater productivity. The main arguments against this change include loss of income to physicians, loss of skilled manpower to the profession and adverse effects on the mental and physical health of retiring physicians. In an effort to resolve this conflict some Canadian hospitals are developing strategies for reviewing the specific privileges and responsibilities physicians will retain once they reach age 65. The medical staff of the Victoria General Hospital in Halifax, NS have addressed this issue through their annual reappointment process.     

Resistance to aminoglycoside antibiotics of gram-negative bacilli isolated in Canadian hospitals.

A survey was made of the frequency of resistance to amikacin, gentamicin and tobramycin among aerobic gram-negative bacilli isolated over a 4-week period in 1979 at six large, geographically separated Canadian hospitals. In the entire series of 4407 isolates the frequency of resistance was 2.5% to amikacin, 8.1% to gentamicin, 5.9% to tobramycin and 1.7% to all three. Most (81%) of the resistant bacteria were acquired by the patients after admission to hospital. The frequency of resistance to the three aminoglycoside antibiotics in each hospital largely reflected the local rate of cross-infection by endemic strains of resistant bacteria.     

Indirect costs of teaching in Canadian hospitals.

We sought to determine whether there are indirect costs of teaching in Canadian hospitals. To examine cost differences between teaching and nonteaching hospitals we estimated two cost functions: cost per case and cost per patient-day (dependent variables). The independent variables were number of beds, occupancy rate, teaching ratio (number of residents and interns per 100 beds), province, urbanicity (the population density of the county in which the hospital was situated) and wage index. Within each hospital we categorized a random sample of patient discharges according to case mix and severity of illness using age and standard diagnosis and procedure codes. Teaching ratio and case severity were each highly correlated positively with the dependent variables. The other variables that led to higher costs in teaching hospitals were wage rates and number of beds. Our regression model could serve as the basis of a reimbursement system, adjusted for severity and teaching status, particularly in provinces moving toward introducing case-weighting mechanisms into their payment model. Even if teaching hospitals were paid more than nonteaching hospitals because of the difference in the severity of illness there should be an additional allowance to cover the indirect costs of teaching.     

Antimicrobial drug use in three Canadian general hospitals.

Total amounts of antimicrobial drugs used to treat inpatients during 1975 were calculated for three Canadian general hospitals, one of them the principal teaching hospital of a medical school. Use of drugs was compared with that reported for Boston City Hospital during periods when antimicrobial therapy was and was not supervised by infectious disease consultants. Ampicillin, tetracyclines, cephalosporins, erythromycin and aminoglycosides for prophylactic oral administration were used excessively in the three hospitals. The degree of overuse was comparable to that at Boston City Hospital during years when drug use was uncontrolled. Overuse or improper choice of antimicrobial drug decreases the quality of patient care and increases its cost. More rigorous education is needed for both medical students and practising physicians in the rational use of antimicrobial drugs. Informal consultation with an infectious disease unit should be required before certain overly popular or toxic antibiotics are administered to hospitalized patients.