Pediatric inpatients had more adverse events at academic hospitals but fewer preventable complications compared with non-academic centers, a review of Canadian hospital data showed.
Adverse events occurred three times more often in academic pediatric hospitals. Analysis by type of adverse event showed nonpreventable complications were more than four times as common in the academic centers, according to Anne G. Matlow, MD, of the Hospital for Sick Children in Toronto, and co-authors.
Surgical complications accounted for a majority of adverse events and were more common in academic centers, whereas complications associated with diagnostic errors occurred more often in non-academic settings, they reported online in CMAJ.
"Our findings are likely not unique to Canada," the investigators wrote in conclusion. "Risk factors for unsafe care in pediatrics are universal, including children's physical characteristics and developmental variability.
"We hope our results catalyze widespread efforts to improve the safety of pediatric healthcare in Canada."
Chart reviews and administrative databases have suggested adverse event rates of 3% or less among children admitted to hospitals. Targeted studies employing clinical trigger tools to identify cases for review have generated discordant data that have taken precedence over chart reviews, the authors noted in their introduction.
The absence of a comprehensive trigger tool for hospitalized pediatric patients has hindered efforts to quantify and characterize the burden of harm associated with hospital admission. The clinically validated Canadian Pediatric Trigger Tool addressed the unmet need for a comprehensive trigger tool to identify adverse events among children admitted to hospitals.
To compare adverse events in academic and non-academic children's hospitals, Matlow and colleagues conducted the Canadian Pediatric Adverse Events Study, using the validated pediatric trigger instrument.
The study comprised seven Canadian geographic regions, each of which had one academic pediatric hospital to two community hospitals. The academic centers were defined by the presence of a full-time core postgraduate training program in pediatrics and pediatric surgery, as well as a level 3 neonatal intensive care unit (NICU).
Eligible community hospitals had 1,000 or more pediatric admissions (including newborns) from April 2008 through March 2009, a NICU or special-care nursery, and no full-time residency training in pediatrics or pediatric surgery.
The analysis comprised 1,680 charts from the academic centers and 1,960 from the community hospitals. The primary outcome was occurrence of any adverse event the occurred within 3 months of admission and that was detected before or within 3 months of discharge.
An adverse event was defined as "an unintended injury or complications caused by healthcare management resulting in disability at discharge, death, prolonged stay in hospital, or a subsequent admission to hospital."
On the basis of individual chart review, independent physicians determined whether an event was preventable, defined as >50% probability of having been caused by healthcare management.
The chart reviewers identified adverse events in 237 patients (9.2%). Four patients died following adverse events; all of them had been admitted to academic hospitals. The overall rate included adverse event rates of 11.2% in academic centers (95% CI 6.4 to 15.9) and 3.3% in community hospitals (95% CI 1.2 to 5.3).
Adverse events occurred significantly more often at academic pediatric hospitals, regardless of patient age (age 0 to 5, RR 3.8, 95% CI 2.7 to 5.6; age greater than 5, RR 2.0, 95% CI 1.2 to 3.2). Considering all adverse events irrespective of age, patients admitted to academic hospitals had significantly higher likelihood of adverse events versus community hospitals (OR 2.98, 95% CI 1.65 to 5.39).
The authors found that 106 of 237 patients (44.7%) had preventable adverse events. The rates of preventable events were 4.1% at academic centers and 2.0% at community hospitals, a difference that did not achieve statistical significance.
Nonpreventable events occurred significantly more often among academic medical centers (OR 4.39, 95% CI 0.4 to 0.80) and were more common across all age groups except newborns.
For all adverse events, clinical services most often associated with the events were surgery (35.1%), medicine (29.8%), and ICU (13.3%).
Primary source: CMAJ