Anthony D. Slonim

BACKGROUND: Blood product transfusions are a valuable health‐care resource. Guidelines for transfusion exist, but variability in their application, particularly in children, remains. The risk factors that threaten transfusion safety are well established, but because their occurrence in children is rare, single‐institution studies have limited utility in determining the rates of occurrence. An epidemiologic approach that investigates blood transfusions in hospitalized children may help improve our understanding of transfused blood products in this vulnerable population.STUDY DESIGN AND METHODS: This was a nonconcurrent cohort study of pediatric patients not more than 18 years of age hospitalized from 2001 to 2003 at 35 academic children's hospitals that are members of the Pediatric Health Information System (PHIS).RESULTS: A total of 51,720 (4.8%) pediatric patients received blood product transfusions during the study period. Red blood cells (n = 44,632) and platelets (n = 14,274) were the two most frequently transfused products. The rate of transfusions was highest among children with neutropenia, agranulocytosis, and sickle cell crisis. Asian and American Indian patients had important differences in the rate of blood transfusions and their complications. Resource use in terms of length of stay and costs were higher in patients who received transfusion. Of those patients who received transfusions, 492 (0.95%) experienced a complication from the administered blood product. This accounted for a rate of complications of 10.7 per 1,000 units transfused.CONCLUSIONS: The administration of blood products to children is a common practice in academic children's hospitals. Complications associated with these transfused products are rare.

Ensuring patient safety is becoming increasingly important for intensive care unit practitioners. The intensive care unit is particularly prone to medical errors because of the complexity of the patients, interdependence of the practitioners, and dependence on team functioning. This review provides historical perspectives, research foundations, and a practical “how to” guide to improving care in the intensive care unit. It also considers the organizational structure, the processes of care, and the occurrence of adverse outcomes in this setting. Effective intensive care unit quality and safety programs capitalize on institutional resources and have multidisciplinary input with clear leadership, input from quality improvement initiatives, a responsible yet nonpunitive culture, and data-driven assessment and monitoring to reduce medical errors. Intensive care unit practitioners need to capitalize on the benefits that patients and their families bring to the patient safety discourse. This provides opportunities for better understanding the risks of the intensive care unit and improving the consent process.

Context. Medical errors are an important problem for hospitalized adult inpatients. However, medical errors in children remain comparatively understudied, and published research has been relatively limited. Objectives. To investigate the national rates of hospital-reported medical errors in pediatric inpatients over the period 1988–1997; and to determine the association of patient and hospital characteristics with the occurrence of hospital-reported medical errors in children. Design, Setting, and Patients. A nonconcurrent cohort study of hospitalized nonnewborn pediatric patients in the United States ≤18 years of age. Data from the Healthcare Cost and Utilization Project for the years 1988, 1991, 1994, and 1997 were used for these analyses. Main Outcome Measure. The occurrence of hospital-reported medical errors. Results. The national rate of hospital-reported medical errors in hospitalized children ranged from 1.81 to 2.96 per 100 discharges. These medical error rates were statistically lower in 1988, with the years 1991, 1994, and 1997 not being statistically different from each other. There were no consistent differences in the rates of medical errors when stratified by gender, race, payor status, or median household income of the patient’s zip code across years. There was, however, a statistically significant relationship between higher median household income and increasing medical error rates; this trend was consistent across all 4 years. Similarly, children with special medical needs or dependence on a medical technology also had significantly higher rates of hospital-reported medical errors. Although hospital size did not seem to be related to the rate of medical errors, private for-profit hospitals consistently reported lower rates, whereas urban teaching hospitals in all years but 1997 reported higher rates of medical errors. Conclusions. These data highlight both the strengths and limitations of administrative data in the investigation of medical errors. Substantively, they suggest fruitful areas for additional and more detailed study, notably children with special medical needs.

To assess the operational and subsidiary costs and length of stay (LOS) attributable to nosocomial bloodstream infections (BSI) in a pediatric intensive care unit (PICU). Matched case-control study. Sixteen bed PICU in a 250-bed tertiary-care pediatric hospital. Cases with BSI were prospectively identified from PICU patients who developed a nosocomial BSI from August 1996 to July 1998. Controls were PICU patients who were matched for age, severity of illness, diagnosis, and admission date who did not develop a nosocomial BSI. A total of 38 cases and 38 controls form the basis for this study. The cases and controls were similar with respect to the matching criteria. In addition, the cases and controls did not differ with respect to demographic characteristics or PICU survival. There was a trend toward increased hospital mortality among cases (23.7% vs. 10.5%, p = .084). Significant differences were encountered in the utilization of PICU therapeutic modalities. Cases were significantly less likely to be managed care plan enrollees (36.8% vs. 60.5%, p = .043). Total operational and subsidiary costs for radiology, pharmacy, and laboratory services were significantly higher for cases than controls ($78,272 vs. $35,005, $3,622 vs. $1,432, $8,635 vs. $4,630, and $8,648 vs. $3,971, respectively; all p < .001). The PICU and hospital LOS were significantly higher for cases than controls (19.3 vs. 4.6 days for PICU and 46.7 vs. 24.4 days for hospital; both p < .001). The operational costs attributable to nosocomial infection were $46,133. Radiology, pharmacy, and laboratory costs attributable to nosocomial infection were $2,364, $4,691, and $5,156, respectively. The PICU and hospital LOS attributable to a nosocomial BSI were 14.6 days and 21.1 days, respectively. The attributable mortality rate was 13.1%. The costs and LOS associated with nosocomial BSI in patients admitted to the PICU were significantly higher than controls.