Children's Hospital of Pittsburgh of the University of Pittsburgh
When young children and adolescents are admitted to the hospital, they face distinct barriers to receiving safe care in a health system largely structured to serve the needs of adults. Research conducted on this issue illustrates clearly that pediatric patients are more likely than adults to experience adverse drug events because of weight-based fractional dosing calculations and the inability of young children to properly communicate with hospital staff regarding adverse effects of medication administration. A landmark 2001 study published in the Journal of the American Medical Association found that the potential for adverse drug events in hospitalized pediatric populations is anywhere from three to five times higher than the potential for inpatient adults1; in 2008, a similar study published in Pediatrics identified an 11.1 percent rate of adverse drug events in pediatric admissions, a rate that translates to 1 event per 1000 medication doses. Within that study group, 22 percent of those adverse drug events were preventable.2
For pediatric hospitals looking to improve patient safety and reduce harm in care delivery, reducing medication errors is central. Children face distinct obstacles to high-quality care, with more unpredictable reactions to medicine and difficulty reporting the particular symptoms of an adverse drug event to a clinician. Making care safer for pediatric patients means that providers must implement innovative care delivery models that minimize the unpredictability of drug therapies while reducing the potential for serious dosage errors that land children back in the hospital.
About Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center
For more than a century, the staff at Children's Hospital of Pittsburgh has delivered safe, high-quality, person-centered pediatric care by emphasizing quality, safety, and innovation. The hospital operates as a standalone teaching hospital within the larger University of Pittsburgh Meducal Center (UPMC) system, which includes more than 20 specialized hospitals. UPMC also functions as an insurance company, providing coverage for more than 1.8 million members.3, 4
As the only major pediatric system for more than 200 miles, many local children and adolescents may receive all of their inpatient and ambulatory care at Children's and its regional facilities within the larger UPMC network. In 2013, Children's received more than 1 million outpatient visits and had 14,250 inpatient stays. In the same time period, physicians at the hospital performed 24,623 surgical procedures.5
Overview of Activities:
In 2002, Children's adopted electronic health records with the hopes that eliminating handwritten orders and human errors in the care delivery process would ensure that each child received the correct care intended by their doctor. Process analysis of gaps in care at Children's revealed that implementing a computerized physician order entry (CPOE) system would do the most to move the hospital toward that goal. Children's leadership spread out implementation over three stages. The initial step was implementing the CPOE system, which provided key decision support for medication dosages for patients in infancy through adolescence. System alerts were designed especially for weight-based dosing for patient medication allergies and interactions in clinical environments in which parents were not present. Next, the Hospital integrated the onsite pharmacy onto the eRecord so pharmacists would receive the same medication and dosing alerts as point-of-care staff. The final implementation step was instituting a Positive Patient Identification (PPID) system, which provided patients with a unique barcoded wristband upon arrival at the hospital. All medication doses prescribed to them during their stay are marked with the same unique barcode. Implementation of the last two steps meant that traditional non-standard fractional dosing, a significant source of human error for pediatric patients, was eliminated entirely. Onsite pharmacists instead measured out single doses for each patient based on information found in the child's eRecord, and point-of-care staff delivered those pre-measured doses to patients after scanning each individual's unique barcoded bracelet and medicine.
The hospital moved to a new campus in 2009, which was designed to fully integrate the eRecord into all steps of the inpatient and outpatient care processes. Each child's entire medical record became instantaneously available on wireless computer carts to all staff treating the child. One year after the new campus opened, Children's was recognized by the Healthcare Information and Management Systems Society (HIMSS) as the first pediatric hospital in the Nation to achieve Stage 7 of electronic health record implementation. This designation recognizes the hospital for delivering care without the use of any paper charts, employing data warehouses to analyze clinical data patterns to improve care, and demonstrating best practices of electronic health record implementation that fully involve and engage clinicians.6
In addition to its other programs, in 2012, Children's Hospital entered into a partnership with Rothman Healthcare to develop the first-ever pediatric version of Rothman Index. The Rothman Index quantifies a patient's condition into a simple graphic format based on vital signs, nursing assessments, and lab results.7 Index graphics are meant to serve as a backup to point of care physicians by providing a historical context for patient care by drawing attention to changes in health that may otherwise be difficult to detect when a patient is handed off between multiple physicians and nurses.8
Since Children's began eRecord implementation in 2002, the hospital has seen a dramatic decrease in medication errors and adverse events. Instituting the PPID system and eliminating fractional weight-based dosing has significantly diminished the potential for human error by requiring staff to scan the barcodes placed on each patient's admission wristband and medication bottles before administering any dosage. This process ensures that the right dosage of the right medication is provided to the right patient at the right time through the right route. Before the hospital used the eRecord, its medication safety event rate was 0.10 incidents per 1,000 doses dispensed,9 a tenth of the national average. In the 6 years since eRecord implementation, the hospital's medication safety event rate dropped by 60 percent to 0.04 incidents per 1,000 doses dispensed. Serious medication errors were also reduced by 92 percent in the same time period.10 Though the hospital recorded steady increases in the number of patients treated each year for the last 6 years, the hospital's medication safety event and error rates consistently remained at rates seen in 2009.11
In-house analysis of the data mined from the record enables the hospital to go a step further and make care safer for future patients. An inter-hospital bioinformatics workgroup co-operated with the University of Pittsburgh feeds Children's data into a machine learning system with the goal of better predicting a patient's rate of readmission as soon as they enter the hospital. In doing so, hospital staff hope to better focus care management resources on those patients who need the most intensive preventive care for readmission. The program shows promising results in initial testing, and official results are expected to become available in late 2015.
Alignment to the National Quality Strategy (NQS):
- Make care safer by reducing harm caused in the delivery of care.
Renowned for its outstanding clinical services, research programs and medical education, Children's Hospital of Pittsburgh of UPMC has helped establish the standards of excellence in pediatric care. From Ambulatory Care to Transplantation and Cardiac Care, talented and committed pediatric experts care for infants, children, and adolescents who make more than 1,000,000 visits to Children's, its many neighborhood locations, and Children's Community Pediatrics practices each year. Learn more about Children's Hospital of Pittsburgh of UPMC.
1 Agency for Healthcare Research and Quality. AHRQ Patient Safety Network. (n.d.). Retrieved from http://psnet.ahrq.gov/resource.aspx? resourceID=2146.
2 The Joint Commission. Preventing pediatric medication errors. (2008). Retrieved from http://www.jointcommission.org/assets/1/18/SEA_39.pdf.
3 University of Pittsburgh Medical Center. Why UPMC? (n.d.). Retrieved from http://www.upmc.com/about/why-upmc/pages/default.aspx.
4 University of Pittsburgh Medical Center. UPMC Insurance Services Division Fast Facts. (n.d.). Retrieved from http://www.upmc.com/about/facts/structure/Pages/insurance-services.aspx.
5 Children's Hospital of Pittsburgh of UPMC. About Children's. (n.d.). Retrieved from http://www.chp.edu/CHP/about%20childrens.
6 HIMSS Analytics. (2014). U.S. EMR adoption model trends. Retrieved from http://www.himssanalytics.org/docs/EMRAM%20Criteria%20Sheet%202014%20v2.pdf
7 BusinessWire. Children's Hospital of Pittsburgh of UPMC Partners with Rothman Healthcare. (2012, February). Retrieved from http://www.businesswire.com/news/home/20120220005166/en/Childrens-Hospital-Pittsburgh-UPMC-Partners-Rothman-Healthcare#.VQyV347F-So.
8 BusinessWire. Children's Hospital of Pittsburgh of UPMC Partners with Rothman Healthcare. (2012, February). Retrieved from http://www.businesswire.com/news/home/20120220005166/en/Childrens-Hospital-Pittsburgh-UPMC-Partners-Rothman-Healthcare#.VQyV347F-So.
9 HIMSS Analytics. Stage 7 Case Studies: UPMC. (n.d.). Retrieved from http://www.himssanalytics.org/emram/stage7caseStudies.aspx?hospID=23.
10 HIMSS Analytics. Children's Hospital of Pittsburgh of UPMC. (2012). Retrieved from https://www.himssanalytics.org/hc_providers/stage7casestudies_UPMC.asp.
11 Children's Hospital of Pittsburgh of UPMC. Patient Safety First: Why are Electronic Medical Records Important to Patients? (n.d.). Retrieved from http://www.chp.edu/CHP/patient safety first.