Comment
Reducing the burden of iatrogenic harm in children
www.thelancet.com Vol 385 April 25, 2015
covering the UK National Health Service in England and Wales, including recommendations for keeping babies with a family history of medium-chain acylCoA dehydrogenase deficiency safe in the neonatal period, for prevention of harm to children from parents with mental health problems, and for nasogastric placement in infants.9 Themes generated from incident reports can help in the design of logic models that can inform quality improvement interventions. Moreover, problems that would be overlooked at a local level because of small numbers can become evident when aggregated across wider areas. Globally, a systematic approach is needed to generate data of this nature and to construct basic metrics of harm in children and young people, and to ensure that these data are reflected within international development goals. The Global Burden of Disease study1 could provide annual estimates of the scale of iatrogenic harm and could inform health policy makers about where to direct efforts to mitigate such harm. WHO has proposed a Minimal Information Model to provide a dataset in all countries for sharing of patient safety incident reports.10 This model could improve understanding of the nature, and particularly the causes, of unsafe care. We believe that present incident reporting systems are undervalued and underused, garnering little respect from the health information and research communities. An international patient safety learning system is needed, designed to describe care failures or safety incidents, shape priorities for improvement, corroborate
AJ Photo/Science Photo Library
In 2013, as many as 6·3 million children worldwide died before their fifth birthday.1 Children have an increased risk of health-care-related harm because of factors including the complexity of prescribing and dispensing of drugs, a reduced physiological reserve compared with adults, and dependency on others (ie, parents and health-care providers) to recognise the emergence of a hazardous situation.2 Despite these factors, little research has been done of the contributions of substandard care and iatrogenic harm to deaths in childhood. Furthermore, health-care-related harm has featured little in the Millennium Development Goals; the Sustainable Development Goals must include this issue, and establish priority to resolve the existing paucity of research related to children and young people and promote policy making for strengthening of healthcare systems to cater for children’s needs.3,4 Confidential enquiries into child deaths in the UK showed that 26% of deaths had identifiable failures in care, and a further 43% had potentially avoidable factors.5,6 In the USA, an estimated 15–35% of children admitted to hospital have health-care-associated harm.7 Despite patient safety being an established health policy concern for adults, little has been done to estimate the frequency of harm and its associated burden in the care of children. Research in adults has shown that a range of methods can be successfully used to study substandard care and iatrogenic harm. Trigger tools can identify, within medical records, features suggestive of adverse events. Safety indices can be constructed from administrative data to estimate what incidents happen, whilst methods such as root cause analyses and incident reporting systems can aid understanding of why incidents happen.7,8 This work now needs to be extended to children and young people. That said, collection, analysis, and use of such data in health care remain problematic, with few health systems showing that they can reduce risk for future patients. In the England and Wales National Reporting and Learning System, more than 65 000 reports of safety incidents involving children are received every year; about 30% of those reports record incidents that resulted in harm or death to children (Carson-Stevens A, unpublished). Useful lessons can be learned from these reports: 77 safety notices were issued between 2004 and 2012 by the National Patient Safety Agency
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Comment
insights from research studies, develop potential solutions for application in practice, and share learning of the context-specific approaches of application of solutions. In view of the different maturity levels of data collection across different economic settings, the system would benefit from a phased effort to develop the necessary infrastructures for data sharing in each country. Member countries of such a system must hold autonomy to undertake their own searches informed by insights gleaned from surveillance of their own national safety data. Moreover, countries need to develop a culture of open reporting from staff, parents, and patients to provide future high-quality incident reports, build improvement capability within their workforce to apply the lessons learned, and educate family and patients for early warning and early action to mitigate care failure. Such development will require a combined enterprise between clinical and patient safety experts and the commitment of health leaders and policy makers. *Andrew Carson-Stevens, Adrian Edwards, Sukhmeet Panesar, Gareth Parry, Philippa Rees, Aziz Sheikh, Liam Donaldson Cochrane Institute for Primary Care and Public Health, Cardiff University, Cardiff CF14 4YS, UK (AC-S, AE, PR); Department of Family Practice, University of British Columbia, Vancouver, BC, Canada (AC-S); Centre of Medical Informatics, University of Edinburgh, Edinburgh, UK (AC-S, SP, AS); Institute for Healthcare Improvement, Cambridge, MA, USA (GP); Harvard Medical School, Boston, MA, USA (GP, AS); Brigham and Women’s Hospital, Boston, MA, USA (AS); and Department of Surgery and Cancer, Imperial College London, London, UK (LD) carson-stevensap@cardiff.ac.uk
AS was supported by The Commonwealth Fund; the other authors declare no competing interests. AC-S and AE are cochief investigators, and SP, AS, and LD coapplicants, on a National Institute of Health Research (NIHR) Health Services and Delivery Research grant to characterise patient safety incident reports in primary care (12/64/118); PR works on, and GP serves on the Professional Advisory Group of, the study. LD was Chairman of the National Patient Safety Agency (NPSA) in 2010–12, is involved in research on the National Reporting and Learning System (NRLS), and is WHO’s Patient Safety Envoy. SP was a former clinical adviser at the NPSA in 2008–10, and works on the NRLS research programme. The views expressed herein are those of the authors and do not necessarily reflect those of the UK Health Services and Delivery Research programme, NIHR, NHS, Department of Health, or The Commonwealth Fund. 1
2 3 4 5
6
7 8 9 10
Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285: 2114–20. Wolfe I, Thompson M, Gill P, et al. Health services for children in western Europe. Lancet 2013; 381: 1224–34. Modi N, Clark H, Wolfe I, et al. A healthy nation: strengthening child health research in the UK. Lancet 2013; 381: 73–87. Pearson GA, ed. Why children die: a pilot study 2006. England (South West, North East & West Midlands), Wales and Northern Ireland. London: CEMACH, 2008. http://www.hqip.org.uk/assets/NCAPOP-Library/CMACEReports/1.-May-2008-Why-Children-Die-A-Pilot-Study-2006.pdf (accessed July 18, 2014). Department for Education. Child death reviews: year ending 31 March 2013. London: Department for Education, 2013. https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/223697/SFR26_2013_Text_ v2.pdf (accessed July 18, 2014). Walsh KE, Bundy DG, Landrigan CP. Preventing health care-associated harm in children. JAMA 2014; 311: 1731–32. Parry G, Cline A, Goldmann D. Deciphering harm measurement. JAMA 2012; 307: 2155–56. NHS. National Patient Safety Agency. Alerts. http://www.nrls.npsa.nhs.uk/ alerts/ (accessed July 18, 2014). WHO. Reporting patient safety incidents. http://www.who.int/patientsafety/ implementation/information_model/en/ (accessed July 18, 2014).
Hip fractures: comprehensive geriatric care and recovery Published Online February 5, 2015 http://dx.doi.org/10.1016/ S0140-6736(14)61592-0 See Articles page 1623
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Hip fractures are a worldwide public health issue, with devastating consequences for both patients and their families. In 2000, 1·6 million hip fractures were reported worldwide1 and epidemiological studies estimate a 12·1% and 4·6% lifetime risk of hip fracture for women and men, respectively.2 Clinical and social consequences of hip fracture include death, depression, fear of falling, disability, institutionalisation, and social isolation.3 For old people, the ability to remain mobile is an essential aspect of quality of life, and is crucial for the preservation of independence. Many older patients develop disabilities in mobility after hip fracture surgery, and more than 30% do not regain independent ambulation
1 year later.4 A better understanding of this suboptimum recovery, and innovative, effective interventions beyond surgery, are clinical and public health priorities. In The Lancet, Anders Prestmo and colleagues5 present their well designed study providing strong evidence that, for patients aged 70 years or older with hip fractures, perioperative comprehensive geriatric care given in a dedicated ward improves short-term and long-term function in mobility, as compared with treatment in a traditional orthopaedic care unit. 198 patients were randomly assigned to comprehensive geriatric care, and 199 to usual orthopaedic care. Mobility was assessed by the trial’s primary endpoint, www.thelancet.com Vol 385 April 25, 2015
Reducing the burden of iatrogenic harm in children
www.thelancet.com Vol 385 April 25, 2015
covering the UK National Health Service in England and Wales, including recommendations for keeping babies with a family history of medium-chain acylCoA dehydrogenase deficiency safe in the neonatal period, for prevention of harm to children from parents with mental health problems, and for nasogastric placement in infants.9 Themes generated from incident reports can help in the design of logic models that can inform quality improvement interventions. Moreover, problems that would be overlooked at a local level because of small numbers can become evident when aggregated across wider areas. Globally, a systematic approach is needed to generate data of this nature and to construct basic metrics of harm in children and young people, and to ensure that these data are reflected within international development goals. The Global Burden of Disease study1 could provide annual estimates of the scale of iatrogenic harm and could inform health policy makers about where to direct efforts to mitigate such harm. WHO has proposed a Minimal Information Model to provide a dataset in all countries for sharing of patient safety incident reports.10 This model could improve understanding of the nature, and particularly the causes, of unsafe care. We believe that present incident reporting systems are undervalued and underused, garnering little respect from the health information and research communities. An international patient safety learning system is needed, designed to describe care failures or safety incidents, shape priorities for improvement, corroborate
AJ Photo/Science Photo Library
In 2013, as many as 6·3 million children worldwide died before their fifth birthday.1 Children have an increased risk of health-care-related harm because of factors including the complexity of prescribing and dispensing of drugs, a reduced physiological reserve compared with adults, and dependency on others (ie, parents and health-care providers) to recognise the emergence of a hazardous situation.2 Despite these factors, little research has been done of the contributions of substandard care and iatrogenic harm to deaths in childhood. Furthermore, health-care-related harm has featured little in the Millennium Development Goals; the Sustainable Development Goals must include this issue, and establish priority to resolve the existing paucity of research related to children and young people and promote policy making for strengthening of healthcare systems to cater for children’s needs.3,4 Confidential enquiries into child deaths in the UK showed that 26% of deaths had identifiable failures in care, and a further 43% had potentially avoidable factors.5,6 In the USA, an estimated 15–35% of children admitted to hospital have health-care-associated harm.7 Despite patient safety being an established health policy concern for adults, little has been done to estimate the frequency of harm and its associated burden in the care of children. Research in adults has shown that a range of methods can be successfully used to study substandard care and iatrogenic harm. Trigger tools can identify, within medical records, features suggestive of adverse events. Safety indices can be constructed from administrative data to estimate what incidents happen, whilst methods such as root cause analyses and incident reporting systems can aid understanding of why incidents happen.7,8 This work now needs to be extended to children and young people. That said, collection, analysis, and use of such data in health care remain problematic, with few health systems showing that they can reduce risk for future patients. In the England and Wales National Reporting and Learning System, more than 65 000 reports of safety incidents involving children are received every year; about 30% of those reports record incidents that resulted in harm or death to children (Carson-Stevens A, unpublished). Useful lessons can be learned from these reports: 77 safety notices were issued between 2004 and 2012 by the National Patient Safety Agency
1593
Comment
insights from research studies, develop potential solutions for application in practice, and share learning of the context-specific approaches of application of solutions. In view of the different maturity levels of data collection across different economic settings, the system would benefit from a phased effort to develop the necessary infrastructures for data sharing in each country. Member countries of such a system must hold autonomy to undertake their own searches informed by insights gleaned from surveillance of their own national safety data. Moreover, countries need to develop a culture of open reporting from staff, parents, and patients to provide future high-quality incident reports, build improvement capability within their workforce to apply the lessons learned, and educate family and patients for early warning and early action to mitigate care failure. Such development will require a combined enterprise between clinical and patient safety experts and the commitment of health leaders and policy makers. *Andrew Carson-Stevens, Adrian Edwards, Sukhmeet Panesar, Gareth Parry, Philippa Rees, Aziz Sheikh, Liam Donaldson Cochrane Institute for Primary Care and Public Health, Cardiff University, Cardiff CF14 4YS, UK (AC-S, AE, PR); Department of Family Practice, University of British Columbia, Vancouver, BC, Canada (AC-S); Centre of Medical Informatics, University of Edinburgh, Edinburgh, UK (AC-S, SP, AS); Institute for Healthcare Improvement, Cambridge, MA, USA (GP); Harvard Medical School, Boston, MA, USA (GP, AS); Brigham and Women’s Hospital, Boston, MA, USA (AS); and Department of Surgery and Cancer, Imperial College London, London, UK (LD) carson-stevensap@cardiff.ac.uk
AS was supported by The Commonwealth Fund; the other authors declare no competing interests. AC-S and AE are cochief investigators, and SP, AS, and LD coapplicants, on a National Institute of Health Research (NIHR) Health Services and Delivery Research grant to characterise patient safety incident reports in primary care (12/64/118); PR works on, and GP serves on the Professional Advisory Group of, the study. LD was Chairman of the National Patient Safety Agency (NPSA) in 2010–12, is involved in research on the National Reporting and Learning System (NRLS), and is WHO’s Patient Safety Envoy. SP was a former clinical adviser at the NPSA in 2008–10, and works on the NRLS research programme. The views expressed herein are those of the authors and do not necessarily reflect those of the UK Health Services and Delivery Research programme, NIHR, NHS, Department of Health, or The Commonwealth Fund. 1
2 3 4 5
6
7 8 9 10
Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285: 2114–20. Wolfe I, Thompson M, Gill P, et al. Health services for children in western Europe. Lancet 2013; 381: 1224–34. Modi N, Clark H, Wolfe I, et al. A healthy nation: strengthening child health research in the UK. Lancet 2013; 381: 73–87. Pearson GA, ed. Why children die: a pilot study 2006. England (South West, North East & West Midlands), Wales and Northern Ireland. London: CEMACH, 2008. http://www.hqip.org.uk/assets/NCAPOP-Library/CMACEReports/1.-May-2008-Why-Children-Die-A-Pilot-Study-2006.pdf (accessed July 18, 2014). Department for Education. Child death reviews: year ending 31 March 2013. London: Department for Education, 2013. https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/223697/SFR26_2013_Text_ v2.pdf (accessed July 18, 2014). Walsh KE, Bundy DG, Landrigan CP. Preventing health care-associated harm in children. JAMA 2014; 311: 1731–32. Parry G, Cline A, Goldmann D. Deciphering harm measurement. JAMA 2012; 307: 2155–56. NHS. National Patient Safety Agency. Alerts. http://www.nrls.npsa.nhs.uk/ alerts/ (accessed July 18, 2014). WHO. Reporting patient safety incidents. http://www.who.int/patientsafety/ implementation/information_model/en/ (accessed July 18, 2014).
Hip fractures: comprehensive geriatric care and recovery Published Online February 5, 2015 http://dx.doi.org/10.1016/ S0140-6736(14)61592-0 See Articles page 1623
1594
Hip fractures are a worldwide public health issue, with devastating consequences for both patients and their families. In 2000, 1·6 million hip fractures were reported worldwide1 and epidemiological studies estimate a 12·1% and 4·6% lifetime risk of hip fracture for women and men, respectively.2 Clinical and social consequences of hip fracture include death, depression, fear of falling, disability, institutionalisation, and social isolation.3 For old people, the ability to remain mobile is an essential aspect of quality of life, and is crucial for the preservation of independence. Many older patients develop disabilities in mobility after hip fracture surgery, and more than 30% do not regain independent ambulation
1 year later.4 A better understanding of this suboptimum recovery, and innovative, effective interventions beyond surgery, are clinical and public health priorities. In The Lancet, Anders Prestmo and colleagues5 present their well designed study providing strong evidence that, for patients aged 70 years or older with hip fractures, perioperative comprehensive geriatric care given in a dedicated ward improves short-term and long-term function in mobility, as compared with treatment in a traditional orthopaedic care unit. 198 patients were randomly assigned to comprehensive geriatric care, and 199 to usual orthopaedic care. Mobility was assessed by the trial’s primary endpoint, www.thelancet.com Vol 385 April 25, 2015
