Precedent (Australian Lawyers Alliance)
UNDERSTANDING PAEDIATRIC ERRORS
By Dr Tessa R Davis
Paediatric doctors make errors, and often end up in court as a result of them. While the fallout of these errors for families and healthcare professionals is clear, what is less clear is which clinical factors contribute to such errors.
This article aims to provide an insight into the clinical context of paediatric error: a combination of human frailty; systems; environment; and cognition. Understanding the clinical causes of errors allows for clearer legal investigation into the issues associated with paediatric error.
Paediatrics is a unique area of specialisation in medical practice. Paediatric doctors prescribe drugs involving complicated calculations; they deal with patients who often cannot speak; and the patients’ size and physiology make investigations technically more difficult.
Paediatric errors typically arise in three key areas: prescribing; diagnosis; and delays in treatment.
MANAGING MATHS IN PAEDIATRIC PRESCRIBING
Prescribing errors are more common, and have more detrimental clinical consequences, in paediatric than in adult patients. Prescribing itself in paediatrics is more complicated. In adults, most drugs are prescribed at a fixed dose and no calculation is required. But in children, most drugs are prescribed based on the patient’s weight, so a calculation is required, which allows scope for error. Drugs are often prescribed ‘off-label’ in paediatrics, which means there is less clear dosing guidance available. Additionally, as children grow from neonates to adolescents, their body’s ability to process medication changes; therefore, even the mg/kg dosing will differ depending on the age of the child. And, finally, a small mistake, which could lead to no harm in an adult, can lead to significant harm in a child, as there is less room for manoeuvre on the dosing. Research has noted an overall prescribing error rate of 23.1 per cent when investigating junior doctors’ prescribing abilities.
Dosing errors are the most common type of prescribing errors. In a 2013 study, 36.5 per cent of the errors involved dosage, with the dose prescribed not being within 25 per cent of the correct dose. Doctors need better training in basic calculations. Glover and Sussmane conducted a simple ten-question test on paediatric residents. These were calculations based on paediatric prescribing, and the doctors were even allowed to use a calculator. The average score was 70 per cent, perhaps reflecting the lack of training in paediatric prescribing. Given that paediatrics is a specialty where calculations are required with each prescription, specific training in prescribing is clearly a key component of error minimisation.
Tenfold errors are a serious and real issue facing paediatric patients. The decimal place being in the wrong spot might seem like an easily identifiable mistake, but with so much variation in medication doses, it is easy to miss. In an adult, making up ten times the correct dose would likely result in a huge volume of medication so would be detected prior to administration. But, in children, where volumes are so small, even a tenfold error might still seem like a reasonable volume and therefore get overlooked.
Prescriptions are still generally handwritten by doctors and then interpreted by the pharmacist or nursing staff. Using abbreviations is a common source of error, such as using ‘u’ for units, which can be read as an extra ‘0’ on the end of a dose, such as for insulin. Other abbreviation issues are route of dosing, frequency of dosing, or adding a trailing zero (for example, ‘5.0mg’). Simple educational interventions for junior doctors such as teaching, prompts and knowledge-testing can reduce such errors.
Most prescribing errors are made by junior doctors (although this is likely to be simply because they do most of the prescribing) and most errors are made on the sickest patients. Strategies to reduce prescribing errors should target junior staff and acute care.
Although some errors can be prevented by improving clinicians’ technical calculation skills, or system changes like electronic prescribing, many errors are cognitive errors. Gordon et al interviewed junior doctors about prescribing errors, and how they felt about the responsibility of prescribing. There was a consensus on factors that contribute to cognitive prescribing errors: poor training; overconfidence/guessing; interruptions; peer pressure; environmental issues; incorrect advice; and new and challenging situations.
Each of these factors needs to be considered when investigating the causes of prescribing errors. Nursing and senior staff can often put junior doctors under pressure to complete tasks, leading to rushing or failure to check prescriptions adequately. Distractions are rife, particularly in emergency departments and where there are critically ill patients – doctors are often doing more than one task at the one time. Junior doctors may even be asked to prescribe drugs that they have never previously prescribed.
Doctors can minimise their risk of prescribing errors by double-checking their scripts, seeking alternative sources of information to confirm any doses, or challenging colleagues when needed. And hospitals can minimise the error rate by creating a culture of safety, encouraging distraction-free prescribing and ensuring that adequate resources are available with dosing information.
DIAGNOSTIC ERRORS WHEN YOUR PATIENTS CAN’T TALK
Diagnostic errors are common across the whole of medicine, with studies showing that they account for around 30 per cent of errors leading to litigation. But the reality is that these errors are under-reported, and the true prevalence is likely to be much higher.
One 2007 study surveyed 1,362 paediatric doctors (junior and senior), working in a mixture of hospital and community paediatrics. Its results showed that 54 per cent of paediatric doctors made a diagnostic error once or twice per month. Generally, these errors did not cause harm, although 45 per cent of doctors reported making diagnostic errors that cause harm more than once or twice per year.
Paediatrics provides some diagnostics challenges that set it apart from adult medicine.
Abdominal pain is an extremely common presentation to paediatric emergency departments. In New South Wales, the statistics show that gastroenteritis is in the top 11 presentations, and abdominal pain is at the top of the list. Diarrhoea and vomiting, constipation, or even just generalised, non-specific abdominal pain are frequently seen and are most commonly non-surgical in treatment/outcome.
Certain clinical signs are red flags for abdominal pain. Bilious vomiting, bloody stools, pain waking the child at night time, and weight loss can all indicate a more sinister underlying cause, which should be taken more seriously. But non-specific symptoms can confuse the diagnosis: for example, patients without a temperature, with diarrhoea, and with a normal appetite are often assumed not to have appendicitis.
Inadequate communication across clinical settings is known to be a contributing factor in diagnostic error in paediatrics. This is particularly relevant in appendicitis, where a surgical diagnosis can present with very ‘medical’ symptoms. While paediatric medical clinicians should be able to spot the obvious signs, some subtleties are better assessed by a paediatric surgeon.
Where appendicitis is being considered as a diagnosis, investigations are commonly performed, but can frequently be falsely reassuring. Being misled by a normal test result is another cause of misdiagnosis. For example, tests for white cell count, c-reactive protein, and sometimes for the presence of procalcitonin are performed as indicators of inflammation, and it does seem that the levels of these markers are significantly higher in patients who have appendicitis. However, this can lead to paediatric doctors being reassured by negative inflammatory markers – normal blood results do not rule out appendicitis.
Children cannot always describe where their pain is and what their symptoms are. Locating the focus of pain in an infant is a clinical skill, as children are frequently unable to indicate where the pain is, or report nausea, and night-time waking is not as clear a red flag indicator in this group. Nance et al noted that in younger children, there is a much higher rate of perforation (74 per cent) and abscess (47 per cent) due to diagnostic delay.
Serious bacterial infection
Detecting serious bacterial infection is part of the skill of being a paediatric doctor, and is one of the main diagnoses that paediatric doctors worry about missing. It is both the Holy Grail and Achilles’ heel of paediatric practice. Fever is a common presentation to paediatric emergency departments, and viral illnesses in children are extremely common, with healthy children suffering from 9 to 12 viral illnesses per year.
Assessing a child with fever and recognising a bacterial infection is a significant concern in paediatrics. Signs of serious infection include: being pale; lethargic; unwell-looking; bulging fontanelle; sunken eyes; reduced skin turgor; grunting; and tachypnoea. Some of these, such as ‘unwell-looking’ or ‘lethargic’ are very subjective. Children regularly look unwell and are pale and tired when they have a temperature. However, physiological markers can also help to differentiate between serious bacterial infections and viral illness – in the latest National Institute for Clinical Excellence guidelines for feverish illness in children, particular note is made of a high heart rate as a warning sign.
Van den Bruel et al aimed to identify clinical markers of serious infection in children in the primary care setting. However, even those with a high likelihood ratio of serious infection still resulted in only a 5 per cent risk of serious bacterial infection. This highlights the difficulties for GPs when deciding whom to send paediatric patients to hospital, and emphasises the challenges for hospital physicians in detecting serious illness.
Many emergency departments (in the UK, US and Australia) now use early warning scores to track physiological markers such as heart rate, respiratory rate, and temperature. The aim is to ensure early detection of serious illness before clinical deterioration occurs, and to avoid the pitfall of inadequate data assessment. These scores tend to categorise children by using a system of colours to indicate degrees of deterioration; for example, moving into the ‘orange’ zone should trigger a nursing or medical review. These systems have been implemented in response to cases where warning signs have either not been noticed, or have been noticed but not acted upon, and children have died as a result. Using these systems is controversial and their helpfulness debatable. One of their main benefits is to encourage nursing or junior staff to report worries to more senior staff. Other benefits include providing an indication of physiological trends; improving patient monitoring and inter-team communication; and flagging serious illness.
However, there is no universal agreement and the current situation is that each hospital or area is using its own early warning score. Such variation causes challenges with validating the efficacy of the scoring systems in research. Consequently, these scores are not supposed to replace clinical judgement and are not an absolute indicator of serious illness.
DELAYS IN TREATMENT OR INVESTIGATION
With the new Clinical Excellence Commission ‘Sepsis Kills’ project, emergency departments in NSW have clearer guidelines than ever on how to recognise and manage sepsis. Any patient presenting to emergency who fulfils the criteria gets automatically placed on the Sepsis Pathway, which specifies that antibiotics should be administered within an hour. Yet delays still occur, and it is essential to understand why this happens. In 2009, the Commission conducted a ‘root cause’ analysis for cases of inadequate recognition and management of sepsis. Some key factors contributed to this failure.
Delay in performing investigations
Paediatric procedures are not straightforward and can often cause undue delay in the patient’s flow through the diagnosis and management process. Many paediatric trainees are not actually competent to perform such common paediatric procedures on completion of their training.
It may be the case that doctors are not given adequate training in procedures, particularly neonatal procedures. In Australia, the Royal Australasian College of Physicians requires all paediatricians to complete six months of neonatal training in a tertiary neonatal unit to ensure competence in performing common neonatal procedures. Trainees also have to complete Directly Observed Procedural Skills (DOPS) assessments for the full range of neonatal procedures. A study in Monash Medical Centre showed that trainees had adequate exposure to IV cannulation, lumbar puncture, intubation, and bag and mask ventilation.
But while all doctors should receive adequate neonatal procedural training before becoming paediatricians, keeping these skills up to date is a different issue. A 2006 survey of doctors and nurses working in delivery units found that 8 per cent had not had any neonatal training within the last two years, and 25 per cent of those in rural units did not feel comfortable with neonatal resuscitation.
Training, supervision during procedures, senior presence at the time of the procedure, and ongoing training and simulation, can all have an effect on the ability of doctors to complete a procedure successfully and in a timely fashion.
Failure to hand over clinical information can also cause delays in implementing a treatment plan, leading to the late administration of antibiotics to sick patients. This is more detrimental in paediatrics, where patients are often unable to communicate with doctors, with correspondingly greater reliance on handover information and documentation. McSweeney et al interviewed trainee paediatric doctors about barriers to handover. The main barriers included interruptions (by pager, other staff and phonecalls); general fatigue; and ambivalence towards the importance of handovers.
This is an area where nurses perform well but doctors traditionally do not. Having uninterrupted handovers should be a basic foundation of safe clinical handover. Other factors, such as having a specific time and place for handovers, make them a more formal event that is easier to keep distraction-free. Formalising handovers also ensures the presence of the necessary clinical staff, rather than allowing people to continue with other work during this period. Senior presence and leadership also increase efficacy as they emphasise the importance of handovers and ensure that someone is in charge of co-ordinating proceedings and making sure that patients are not missed. A clear handover framework can also help to reduce handover communication errors, as it ensures that clinicians deliver patient information in a standardised and structured way to avoid errors of omission. Most workplaces, including NSW Health, have implemented guidelines around clear handover. NSW Health uses ISBAR as its structure (Introduction, Situation, Background, Assessment, Recommendation) but there are other similar structures such as I-PASS.
While these strategies can work in a general hospital setting, implementing them in an emergency department can be more challenging due to frequency of shift changes, staff workload, and the transience of patients.
Standardisation of handover procedure and proper staff training are the key to minimising errors.
Paediatrics is a specialty prone to errors. With families in a high state of distress, and patients who cannot communicate, there are many stages in a paediatric patient’s journey where mistakes can happen.
Prescribing errors, incorrect diagnosis, and delay in administering antibiotics are common sources of paediatric errors. Each of these can be minimised by understanding educational, systematic, and cognitive factors contributing to these paediatric errors. Improved communication clear guidelines, and good senior support will all minimise the potential for error in paediatrics.
Dr Tessa R Davis is a paediatric registrar working in Sydney. She has been involved with research and quality improvement projects to reduce paediatric error on topics including prescribing errors, clinical handover, early warning scores, and blood labelling.EMAIL firstname.lastname@example.org.
 Blum KV, Abel SR, Urbanski CJ, Pierce JM, 'Medication error prevention by pharmacists' (1988) 45(9) American Journal of Hospital Pharmacy 1902-3. http://www.nps.org.au/media-centre/media-releases/repository/Off-label-prescribing-what-does-it-mean.
 R LS, MR C, NR B, 'Guidelines for preventing medication errors in pediatrics' (2001) 6 Journal of Pediatric Pharmacology and Therapeutics 426-42.
 Fortescue EB, Kaushal R, Landrigan CP, et al, 'Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients' (2003) 111 (4 Pt 1) Pediatrics 722-9.
 Davis T, Thoong H, Kelsey A, Makin G, 'Categorising paediatric prescribing errors by junior doctors through prescribing competency assessment: does assessment reflect actual practice?' (2013) 69(5) European Journal of Clinical Pharmacology 1163-6.
 Glover ML and Sussmane JB, 'Assessing pediatrics residents' mathematical skills for prescribing medication: a need for improved training' (2002) 77(10) Academic Medicine 1007-10.
 Dooley MJ, Wiseman M, Gu G, 'Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation' (2012) 42(3) Intern Medicine Journal e19-22.
 SE T, MT C, LE H, A M, T T-P, 'An intervention to reduce the use of error-prone prescribing abbreviations in the emergency department' (2007) 37(3) Journal of Pharmacy Practice and Research 214-16.
 Kozer E, Scolnik D, Macpherson A, et al.,'Variables associated with medication errors in pediatric emergency medicine' (2002) 110(4) Pediatrics 737-42.
 Johnson KB, Lehmann CU, Council on Clinical Information Technology of the American Academy of Pediatrics, 'Electronic prescribing in pediatrics: toward safer and more effective medication management' (2013) 131(4) Pediatrics e1350-6.
 Gordon M, Catchpole K, Baker P, 'Human factors perspective on the prescribing behavior of recent medical graduates: implications for educators' (2013) 4 Advances in Medical Education and Practice 1-9.
 Gordon M, Darbyshire D, Baker P, 'Non-technical skills training to enhance patient safety: a systematic review' (2012) 46(11) Medical Education 1042-54.
 Carroll AE, Buddenbaum JL, 'Malpractice claims involving pediatricians: epidemiology and etiology' (2007) 120(1) Pediatrics 10-17.
 Singh H, Thomas EJ, Wilson L, et al, 'Errors of diagnosis in pediatric practice: a multisite survey' (2010) 126(1) Pediatrics 70-9.
 Government N, Recognition of the sick child – http://www.nswhealth.moodle.com.au/DOH/Recognition_Sick_Child1.html.
 Motamed F, Mohsenipour R, Seifirad S, et al, 'Red flags of organic recurrent abdominal pain in children: study on 100 subjects' (2012) 22(4) Iran Journal of Pediatrics 457-62.
 Reynolds SL, 'Missed appendicitis in a pediatric emergency department' (1993) 9(1) Pediatric Emergency Care 1-3.
 See note 15 above.
 Appendicitis is a surgical problem in that it is managed by the surgeons and treated with an operation. Some symptoms and signs are classically surgical – vomiting bile, rigid abdomen. Other symptoms and signs are very medical, and would not necessarily indicate a surgical problem (for example, diarrhoea, nausea, temperature).
 Cappendijk VC, Hazebroek FW, 'The impact of diagnostic delay on the course of acute appendicitis' (2000) 83(1) Archives of Disease in Childhood 64-6.
 See note 15 above.
 Kwan KY, Nager AL, 'Diagnosing pediatric appendicitis: usefulness of laboratory markers' (2010) 28(9) The American Journal of Emergency Medicine 1009-15.
 Nance ML, Adamson WT, Hedrick HL, 'Appendicitis in the young child: a continuing diagnostic challenge,' (2000) 16(3) Pediatric Emergency Care 160-2.
 See note 15 above.
 Roland D, Oliver A, Edwards ED, Mason BW, Powell CVE, 'Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?' (2014) 99(1) Archives of Disease in Childhood 26-9.
 Davis T, 'NICE guideline: feverish illness in children – assessment and initial management in children younger than 5 years' (2013) 98(6) Archives of Disease in Childhood - Education and Practice 232-5.
 Van den Bruel A, Haj-Hassan T, Thompson M, Buntinx F, Mant D, European Research Network on Recognising Serious Infection investigators, 'Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review' (2010) 375(9717) Lancet 834-45.
 Roland D, 'Paediatric Early Warning Scores: Holy Grail and Achilles' heel' (2012) 97(6) Archives of Disease in Childhood – Education and Practice 208-15.
 Hooper AJ, Tibballs J, 'Comparison of a Trigger Tool and voluntary reporting to identify adverse events in a paediatric intensive care unit' (2014) 42(2) Anaesthesia and intensive care 199-206.
 NSW Clinical Excellence Commission, 'Sepsis Kills’ – http://www.cec.health.nsw.gov.au/programs/sepsis.
 NSW Clinical Excellence Commission, 'Clinical focus report from review of root cause analysis and/or incident information management system (IIMS) data recognition and management of sepsis (2009). Accessed at http://www.cec.health.nsw.gov.au/__documents/programs/patient-safety/2013/patient-safety-report-falls-web.pdf.
 Gaies MG, Landrigan CP, Hafler JP, Sandora TJ, 'Assessing procedural skills training in pediatric residency programs' (2007) 120(4) Pediatrics 715-22.
 Ang H, Veldman A, Lewis A, Carse E, Wong FY, 'Procedural training opportunities for basic pediatric trainees during a 6-month rotation in a level III perinatal centre in Australia' (2012) 25(11) The Journal of Maternal-Foetal and Neonatal Medicine 2428-31.
 Foster K, Craven P, Reid S, 'Neonatal resuscitation educational experience of staff in New South Wales and Australian Capital Territory hospitals' (2006) 42(1-2) Journal of Paediatrics and Child Health 16-19.
 McSweeney ME, Lightdale JR, Vinci RJ, Moses J, 'Patient handoffs: pediatric resident experiences and lessons learned' (2011) 50(1) Clinical Pediatrics 57-63.
 Chu ES, Reid M, Schulz T, et al, 'A structured handoff program for interns' (2009) 84(3) Academic Medicine 347-52.
 Australian Resource Centre for Healthcare Innovations, Safe Clinical Handover Programme in NSW – http://www.archi.net.au/documents/resources/qs/clinical/clinical-handover/gp-hospital/Safe_Clinical_Handover.pdf.
 I: illness severity; P: patient summary; A: action items; S: situation awareness and contingency planning; S: synthesis by receiver.