Ten strategies to make the care of children safer

October 10, 2005

Despite the best efforts of clinicians, accidents still occur in pediatric care settings. Speaking from the American Academy of Pediatrics' Conference and Exhibition in Washington, D.C., this week, Marlene Miller, MD, MSc, and Uma Kotagal, MD, MBBS, MSc, presented an audience of pediatricians with 10 strategies for improving the safety of that care in inpatient and outpatient settings, based on their experiences and studies.

Despite the best efforts of clinicians, accidents still occur in pediatric care settings. Speaking from the American Academy of Pediatrics' Conference and Exhibition in Washington, D.C., this week, Marlene Miller, MD, MSc, and Uma Kotagal, MD, MBBS, MSc, presented an audience of pediatricians with 10 strategies for improving the safety of that care in inpatient and outpatient settings, based on their experiences and studies.

Dr. Kotagal, vice president of quality and transformation at Cincinnati Children's Hospital Medical Center, and Dr. Miller, director of quality and safety initiatives at Johns Hopkins Children's Center, broke down those 10 steps into three subcategories: The culture and science of safety; types of errors; and patient safety solutions.

Strategy #1: Create a "climate of safety" survey. An organization can use that survey to gain information about the perceptions of front-line clinical staff. Areas probed by the survey include "I would feel safe being treated here as a patient," "Briefings are common here," and "Medical questions are handled appropriately."

Strategy #2: Conduct safety "walk-arounds," meaning that leaders (such as the chief of surgery or department chairman) have a set time to walk around the ward to ask about safety concerns the staff may have.

Strategy #3: Apply the science of safety and reliability. Reliability science can help design processes that reduce errors to deliver close-to-perfect care. According to Dr. Kotagal, most health care processes have an error rate of 50%; to achieve high reliability requires three levels of action:

  • Level 1: Apply intent, vigilance, and hard work (such as creating personal checklists to ensure that certain tasks have been completed)
  • Level 2: Design systems that are informed by reliability science and research into human variables (standardizing processes, taking advantage of existing habits and patterns, and creating redundancy)


  • Level 3: Design integrated care systems (that is, design procedures to make failures visible and procedures to fix those failures).

Strategy #4:

Systematically identify errors using "trigger tools." This is a means of identifying adverse events, a useful way to build surveillance systems and track improvements. In Drs. Miller's and Kotagal's trial of these strategies, they found that errors related to the prescribing and administration of potassium, insulin, and opiates are the most common ones that lead to adverse events.

Strategy #5: Create an error reporting system. Once an error has been reported into an on-line error reporting system, for example, an instantaneous e-mail message is sent to administrators. Some of the types of errors that can be entered into the system are medication errors, equipment malfunctions, and adverse drug reactions.

Strategy #6: Reduce catheter-related bloodstream infections.

Strategy #7: Form a rapid response team, or RRT. Each member is assigned a specific role that he or she is trained to fill so that, when an emergency occurs, the response process proceeds smoothly.

Strategy # 8: Provide influenza vaccination for at-risk patients in the outpatient setting. (Remember that influenza and its complications account for 10% to 12% of hospitalizations.) Preplanning to have supplies on hand and opening flu vaccine clinics are just two ways to make the care setting safer.

Strategy # 9: Screen for medication effectiveness and side effects in the outpatient setting.

Strategy # 10: Develop solutions to information technology problems, or what Dr. Miller calls "IT Band-Aids." These fixes are tools for common situations, such as emergency medication cards and infusion drip calculations.