Introducing PIPSQC Pediatric International Patient Safety and Quality Collaborative

1. Introducing PIPSQCPediatric International  Patient Safety and Quality Collaborative Peter Lachman Great Ormond Street and the Royal Free Hospitals London

2. A case history Teenager X came into hospital for minor surgery to his hand He was 15 years old and had Becker�s muscular dystrophy On a Saturday morning he was given an anesthetic and reacted and died an hour later The reaction was a rare side-effect that can occur in his condition

3. What protection is needed?

4. The challenge for children Children face different challenges in health care compared to adults they have limited communication skills developmental differences pharmacokinetic variability dependency on adults. We cannot assume that solutions to adult patient safety issues can be readily transferred to pediatrics. Our knowledge of adverse events (AEs) related to pediatric care is in its infancy; reported rates of AEs have ranged from 0.6%-74%, depending on the pediatric population studied and methodologies used.

5. Safety in prescribing �Teaching of paediatric prescribing takes place mostly in the format of lectures during doctors� induction. Few centres assess competency and no validated tool exists. There has been little evaluation of the impact of teaching on competency to prescribe.� Educational interventions to reduce prescribing errors S Conroy, C North, T Fox, L Haines, C Planner, P Erskine, I Wong, H Sammons Arch. Dis. Child 2008;93;313-315 �The safety and well-being of the patient need to be the first concern of any healthcare professional, regardless of that patient�s age. How do we ensure safe prescribing for children?� How do we ensure safe prescribing for children? Helen Sammons, Sharon Conroy Archives of Disease in Childhood 2008;93:98-99

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7. A small beginning PIPSQC has defined a framework to identify the unique paediatric patient safety needs Using this framework and existing science, PIPSQC aims to identify the top priorities for paediatric patient safety improvement. PIPSQC is creating a mechanism to provide paediatric safety content internationally. Our goal is safe health care for children worldwide.

8. We need to measure For safe paediatric health care, we need meaningful metrics, age and developmentally-appropriate solutions, and research into pediatric-specific patient safety issues. Unfortunately given fewer pediatric patients, providers and safety experts in any given location and less resources for pediatric patient safety, improvements may be slower and risk higher.

9. Aims for PIPSQC Facilitate linkages and relationships. Stimulate interaction among members and member institutions. Enable members to learn from one another through the sharing of issues, ideas, best practices, lessons learned, problems and their solutions, research findings and other relevant aspects of mutual interest. Through a collaborative, collective knowledge and experience in could be leveraged to generate new knowledge and share learning with others, in order to generate tangible, measurable improvements in patient safety, practices and patient outcomes.

10. Aims for today Develop the theme that children are different Examine the human factors that impact on children Discuss a paediatric trigger tool

11. Some references Brennan TA, et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. N Engl Med J 1991; 2324: 370-376. Davis P et al. Adverse events in NZ public hospitals. JNZMA 2002, 115: 211-215 Woods D, Thomas E, et al. Adverse Events and Preventable Adverse Events in Children. Paediatrics 2005; 115: 155 Miller MR, Elixhauser A, Zhan C. Patient safety events during pediatric hospitalizations. Pediatrics. 2003; 111(6 Pt 1): 1358 Sharek PJ, Horbar JD, Mason W, Bisarya H, Thurm CW, Suresh G, Gray JE, Edwards WH, Goldmann D, Classen D "Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs." Pediatrics. 2006; 118: 4: 1332-40 Development, Testing, and Findings of a Pediatric-Focused Trigger Tool to Identify Medication-Related Harm in US Children's Hospitals Takata, GS, Mason W, Taketomo C, Logsdon T, and Sharek, MD PJ. Pediatrics 121 No. 4 April 2008, pp. e927-e935

12. Contacts The PIPSQC Executive Anne Matlow anne.matlow@sickkids.ca Karen Dunn karen.dunn@rch.org.au Peter Lachman lachmp@gosh.nhs.uk Matt Scanlon mscanlon@mcw.edu We will email copies of talks