Alisa Khan

Pyridoxine supplementation for the treatment of levetiracetam-induced behavior side effects in children: Preliminary results

Behavioral side effects related to the use of levetiracetam (LEV) in epilepsy are increasingly being recognized. Patients followed in our center have reported improvement of these side effects after starting pyridoxine (vitamin B(6)) supplements. Using mailed questionnaires, retrospective chart reviews, and phone call follow-ups, we analyzed 42 pediatric patients who had been treated with LEV and pyridoxine. Twenty-two patients started pyridoxine after being on LEV, and significant behavioral improvement was observed in nine (41%), no effect in eight (36%), deterioration in four (18%), and an uncertain effect in one. The effects of pyridoxine supplementation were observed during the first week. The remaining patients (20) were already on pyridoxine before LEV was started, started pyridoxine and LEV at the same time, or took pyridoxine intermittently. Pyridoxine is an easily available, inexpensive, and safe therapeutic option. Given these preliminary results, we plan to conduct a placebo-controlled cross-over study to better characterize these observations.

Parent-Reported Errors and Adverse Events in Hospitalized Children

IMPORTANCE Limited data exist regarding the incidence and nature of patient- and family-reported medical errors, particularly in pediatrics. OBJECTIVE To determine the frequency with which parents experience patient safety incidents and the proportion of reported incidents that meet standard definitions of medical errors and preventable adverse events (AEs). DESIGN, SETTING, AND PARTICIPANTS We conducted a prospective cohort study from May 2013 to October 2014 within 2 general pediatric units at a childrens hospital. Included in the study were English-speaking parents (N = 471) of randomly selected inpatients (ages 0-17 years) prior to discharge. Parents reported via written survey whether their child experienced any safety incidents during hospitalization. Two physician reviewers classified incidents as medical errors, other quality issues, or exclusions (κ = 0.64; agreement = 78%). They then categorized medical errors as harmful (ie, preventable AEs) or nonharmful (κ = 0.77; agreement = 89%). We analyzed errors/AEs using descriptive statistics and explored predictors of parent-reported errors using bivariate statistics. We subsequently reviewed patient medical records to determine the number of parent-reported errors that were present in the medical record. We obtained demographic/clinical data from hospital administrative records. MAIN OUTCOMES AND MEASURES Medical errors and preventable AEs. RESULTS The mean (SD) age of the 383 parents surveyed was 36.6 (8.9) years; most respondents (n = 266) were female. Of 383 parents surveyed (81% response rate), 34 parents (8.9%) reported 37 safety incidents. Among these, 62% (n = 23, 6.0 per 100 admissions) were determined to be medical errors on physician review, 24% (n = 9) were determined to be other quality problems, and 14% (n = 5) were determined to be neither. Thirty percent (n = 7, 1.8 per 100 admissions) of medical errors caused harm (ie, were preventable AEs). On bivariate analysis, children with medical errors appeared to have longer lengths of stay (median [interquartile range], 2.9 days [2.2-6.9] vs 2.5 days [1.9-4.1]; P = .04), more often had a metabolic (14.3% vs 3.0%; P = .04) or neuromuscular (14.3% vs 3.6%; P = .05) condition, and more often had an annual household income greater than

Treatments and perceptions of epilepsy in Kashmir and the United States: a cross-cultural analysis

100,000 (38.1% vs 30.1%; P = .06) than those without errors. Fifty-seven percent (n = 13) of parent-reported medical errors were also identified on subsequent medical record review. CONCLUSIONS AND RELEVANCE Parents frequently reported errors and preventable AEs, many of which were not otherwise documented in the medical record. Families are an underused source of data about errors, particularly preventable AEs. Hospitals may wish to consider incorporating family reports into routine safety surveillance systems.

Physician and Nurse Nighttime Communication and Parents' Hospital Experience.

Treatments and perceptions of epilepsy have been found to vary across cultures. This study draws on a comparison of two patient samples, one from the United States (n=28), the other from Kashmir (n=29), to gauge the similarities and differences in social perceptions of epilepsy, attitudes toward conventional and alternative treatments, practice of conventional and alternative treatments, and selected quality-of-life issues. While both the Kashmiri and American patients interviewed were prescribed a similar regimen of traditional antiepileptic drugs, a wider range of drugs and treatments were available to and used by the latter. The use of adjunctive spiritual therapies was more prevalent in the Kashmiri sample, and the use of alternative, nonpharmacological therapies was more prevalent in the American sample. Quality of life for the Kashmiri patients sampled was found to be poorer in terms of educational and occupational opportunities, feelings of stigmatization, and openness with others about the illness. Although the two patient populations interviewed differed in their access to resources and approaches to the disorder, both samples were found to be similar overall in many attitudes and practices relating to epilepsy and its treatment.

Families as Partners in Hospital Error and Adverse Event Surveillance

BACKGROUND AND OBJECTIVE: Night teams of hospital providers have become more common in the wake of resident physician duty hour changes. We sought to examine relationships between nighttime communication and parents’ inpatient experience. METHODS: We conducted a prospective cohort study of parents (n = 471) of pediatric inpatients (0–17 years) from May 2013 to October 2014. Parents rated their overall experience, understanding of the medical plan, quality of nighttime doctors’ and nurses’ communication with them, and quality of nighttime communication between doctors and nurses. We tested the reliability of each of these 5 constructs (Cronbach’s α for each >.8). Using logistic regression models, we examined rates and predictors of top-rated hospital experience. RESULTS: Parents completed 398 surveys (84.5% response rate). A total of 42.5% of parents reported a top overall experience construct score. On multivariable analysis, top-rated overall experience scores were associated with higher scores for communication and experience with nighttime doctors (odds ratio [OR] 1.86; 95% confidence interval [CI], 1.12–3.08), for communication and experience with nighttime nurses (OR 6.47; 95% CI, 2.88–14.54), and for nighttime doctor–nurse interaction (OR 2.66; 95% CI, 1.26–5.64) (P < .05 for each). Parents provided the highest percentage of top ratings for the individual item pertaining to whether nurses listened to their concerns (70.5% strongly agreed) and the lowest such ratings for regular communication with nighttime doctors (31.4% excellent). CONCLUSIONS: Parent communication with nighttime providers and parents’ perceptions of communication and teamwork between these providers may be important drivers of parent experience. As hospitals seek to improve the patient-centeredness of care, improving nighttime communication and teamwork will be valuable to explore.

Engaging Families as True Partners During Hospitalization

Importance Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. Objective To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. Design, Setting, and Participants We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; &kgr;, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. Main Outcomes and Measures Error and AE rates. Results Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates. Conclusions and Relevance Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Weight Loss and Melena in an Adolescent Female

Communication failures are a leading cause of sentinel events, the most serious adverse events that occur in hospitals.1 Interventions to improve patient safety have focused on communication between healthcare providers.2-4 Interventions focusing on communication between providers and families or other patient caregivers are under-studied.5,6 Given their availability, proximity, historical knowledge, and motivation for a good outcome,7 families can play a vital role as “vigilant partners”8 in promoting hospital communication and safety. In this month’s Journal of Hospital Medicine, Solan et al. conducted focus groups and interviews of 61 caregivers of hospitalized pediatric patients at 30 days after discharge to assess their perceptions of communication during hospitalization and discharge home.9 They identified several caregiver themes pertaining to communication between the inpatient medical team and families, communication challenges due to the teaching hospital environment, and communication between providers. Caregiver concerns included feeling out of the loop, excessive provider use of medical jargon, confusing messages on rounds, and inadequate communication between inpatient and outpatient providers. The manuscript serves both to uncover family concerns that may be underappreciated by clinicians and suggest some potential solutions. For instance, caregivers can be apprehensive about whom to call for postdischarge advice because they are sometimes uncertain whether their outpatient providers have sufficient information about the hospitalization to properly advise them. The authors propose using photo “face sheets” to improve caregiver identification of healthcare provider roles, including families in hospital committees, improving transition communication between inpatient and outpatient healthcare providers through timely faxed discharge summaries and telephone calls, and informing families about such communications with their outpatient providers. These are important suggestions. However, in order to move from promoting communication alone to promoting true partnership in care, there are additional steps that providers can take to fully engage families in hospital and discharge communications. Meaningful family engagement in hospital communications—eg, during family-centered rounds (FCRs)—has been associated with improved patient safety and experience.10-12 To further enhance family partnership in care, we would make the following 3 suggestions for hospitals and healthcare providers: (1) focus on health literacy in all communications with families, (2) work towards shared decision making (SDM), and (3) make discharges family-centered.

Same-Hospital Readmission Rates as a Measure of Pediatric Quality of Care

A 14-year-old female presented to her pediatrician’s office with dizziness, fatigue, and pallor for 5 days. Because of severe anemia (hemoglobin of 5.2 g/dL), she was referred to the emergency department for further management. She endorsed a 12-pound weight loss over the past 3 months but denied any fevers, chills, joint pain, upper respiratory infection symptoms, mucosal bleeding, menorrhagia, hematochezia, abdominal pain, bowel changes, lower extremity edema, or excessive nonsteroidal antiinflammatory drug use. Past medical history was notable for Henoch Schonlein purpura at age 6 years presenting with hematuria and melena following upper respiratory illness and requiring steroids, and removal of 2 compound congenital nevi at age 13 years. There was no family history of malignancy, hematologic, gastrointestinal, or rheumatologic disease. Physical examination in the emergency department revealed a weight of 64.6 kg, temperature of 36.4°C, pulse of 104, respirations of 18 breaths/minute, and blood pressure of 117/53 mm Hg. In general, she was mildly overweight and tired appearing. There was significant pallor of conjunctiva, but no scleral icterus or mucosal lesions. There was no cervical or supraclavicular lymphadenopathy. Cardiovascular exam revealed tachycardia and a soft systolic flow murmur. Respiratory exam and abdominal exams were unremarkable. Dermatologic exam revealed no dysplastic appearing lesions, nevi, telangiectasias, purpura, or petechiae. Musculoskeletal exam was without any joint swelling or edema. Rectal exam was guaiac positive with gross melena and a midline rectal skin tag. Laboratory evaluation revealed a white blood cell count of 4.8 x10 /uL, hemoglobin of 5.1 g/dL, hematocrit of 18.6%, mean corpuscular volume of 57.6 fL, and reticulocyte count of 1.6%. Iron studies revealed iron of 8 mcg/dL, transferrin of 362 mg/dL, total iron binding capacity of 2 mg/dL. Peripheral smear was consistent with irondeficiency anemia. Urinalysis, coagulation studies, and serum electrolytes were normal. Serum IgA, tissue transglutaminase IgA, and fecal Helicobacter pylori antigen were all unremarkable. Final Diagnosis