Christina L. Cifra

Diagnostic Errors in a PICU: Insights from the Morbidity and Mortality Conference

Objectives: To describe diagnostic errors identified among patients discussed at a PICU morbidity and mortality conference in terms of Goldman classification, medical category, severity, preventability, contributing factors, and occurrence in the diagnostic process. Design: Retrospective record review of morbidity and mortality conference agendas, patient charts, and autopsy reports. Setting: Single tertiary referral PICU in Baltimore, MD. Patients: Ninety-six patients discussed at the PICU morbidity and mortality conference from November 2011 to December 2012. Interventions: None. Measurements and Main Results: Eighty-nine of 96 patients (93%) discussed at the PICU morbidity and mortality conference had at least one identified safety event. A total of 377 safety events were identified. Twenty patients (21%) had identified misdiagnoses, comprising 5.3% of all safety events. Out of 20 total diagnostic errors identified, 35% were discovered at autopsy while 55% were reported primarily through the morbidity and mortality conference. Almost all diagnostic errors (95%) could have had an impact on patient survival or safety. Forty percent of errors did not cause actual patient harm, but 25% were severe enough to have potentially contributed to death (40% no harm vs 35% some harm vs 25% possibly contributed to death). Half of the diagnostic errors (50%) were rated as preventable. There were slightly more system-related factors (40%) solely contributing to diagnostic errors compared with cognitive factors (20%); however, 35% had both system and cognitive factors playing a role. Most errors involved vascular (35%) followed by neurologic (30%) events. Conclusions: Diagnostic errors in the PICU are not uncommon and potentially cause patient harm. Most appear to be preventable by targeting both cognitive- and system-related contributing factors. Prospective studies are needed to further determine how and why diagnostic errors occur in the PICU and what interventions would likely be effective for prevention.

Transforming the Morbidity and Mortality Conference to Promote Safety and Quality in a PICU

Objective: Determine the effectiveness of a structured systems-oriented morbidity and mortality conference in improving the process of reviewing and responding to adverse events in a PICU. Design: Prospective time series analysis before and after implementation of a systems-oriented morbidity and mortality conference. Setting: Single tertiary referral PICU in Baltimore, MD. Patients: Thirty-three patients discussed before and 31 patients after implementation of a systems-oriented morbidity and mortality conference over a total of 20 morbidity and mortality conferences, from April 2013 to March 2014. Interventions: Systems-oriented morbidity and mortality conference incorporating elements of medical incident analysis. Measurements and Main Results: There was a significant increase in meeting attendance (mean, 12 vs 31 attendees per morbidity and mortality conference; p < 0.001) after the systems-oriented morbidity and mortality conference was instituted. There was no significant difference in the mean number of cases suggested (4.2 vs 4.6) or discussed (3.3 vs 3.1) per morbidity and mortality conference. There was also no significant difference in the mean number of adverse events identified per morbidity and mortality conference (3.4 vs 4.3). However, there was an increase in the proportion of cases discussed using a standard case review tool, but this did not reach statistical significance (27% vs 45%; p = 0.231). Nevertheless, we observed a significant increase in the mean number of quality improvement interventions suggested (2.4 vs 5.6; p < 0.001) and implemented (1.7 vs 4.4; p < 0.001) per morbidity and mortality conference. All adverse event categories identified had corresponding interventions suggested after the systems-oriented morbidity and mortality conference was instituted compared with before (80% vs 100%). Intervention-to-adverse event ratios per category were also higher (mean, 0.6 vs 1.5). Conclusions: A structured systems-oriented PICU morbidity and mortality conference incorporating elements of medical incident analysis improves the process of reviewing and responding to adverse events by significantly increasing quality improvement interventions suggested and implemented. Future work would involve testing locally adapted versions of the systems-oriented morbidity and mortality conference in multiple inpatient settings.

The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit

Objective To determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding safety event occurrence and characteristics. Design Retrospective record review. Setting Single tertiary referral PICU in Baltimore, Maryland, USA. Participants 96 patients discussed at the PICU MMC over 14 months (November 2011–December 2012). Main outcome measures Safety events and their characteristics (medical error category, severity and preventability). Results A total of 275 safety events were identified through the MMC and/or chart review. The MMC identified 131 (48%) events, 53 (19%) of which were identified through the MMC alone. After chart review was performed, an additional 144 (52%) events were identified. 78 (28%) events were identified through both. High severity adverse events potentially contributing to permanent harm or death were more likely to be identified through both the MMC and chart review (47%) compared with either alone. The MMC alone identified more near-misses (21%) and preventable events (96%) compared with chart review alone or both MMC and chart review. Although chart review alone helped to identify many healthcare-associated infections, medication errors and sedation/pain control issues not elicited through the MMC, the MMC alone identified more communication errors and workflow problems. The MMC alone also identified 40% of all diagnostic errors, which would not have been discovered otherwise despite chart review by itself identifying 50% of such misdiagnoses. Conclusions Standardised chart review applied to records of patients discussed at a PICU MMC identified significantly more safety events not initially discovered through the MMC. However, the MMC was superior to chart review in identifying broader problems such as communication errors, workflow issues and certain diagnostic errors not captured by chart review, which can potentially affect many aspects of care.

Antenatal factors modulate hearing screen failure risk in preterm infants

Objective The objective of this study was to characterise the effects of antenatal inflammatory factors and maternal therapies on neonatal hearing screen outcomes in very low birthweight infants. Methods We conducted a retrospective study of a cohort of infants <33 weeks’ gestational age and <1501 g birth weight prospectively enrolled between 1999 and 2003 for whom placental pathology, cord blood interleukin (IL) 6, IL-1ß, tumour necrosis factor-α and neonatal hearing screen results were available. Results Of 289 infants with documented hearing screen results, 244 (84%) passed and 45 (16%) failed the hearing screen (unilateral, N=25 (56%); bilateral, N=20 (44%)). In the final logistic model, the fetal inflammatory response syndrome defined as the presence of fetal vasculitis and/or cord serum IL-6>18.2 pg/mL was the factor with greatest risk for hearing screen failure (OR 3.62, 95% CI 1.38 to 9.5). A patent ductus arteriosus treated with indomethacin significantly increased the risk (OR 3.3, 95% CI 1.3 to 8.26), while combined maternal steroid and magnesium sulfate exposure (0.37, 95% CI 0.11 to 0.81) reduced the risk for hearing screen failure. Conclusions Intrauterine infection with a fetal inflammatory response is a risk factor for neonatal hearing loss while maternal therapies significantly reduced the risk of neonatal hearing loss in very low birthweight infants.

Unexpected Death of a Child with Complex Febrile Seizures—Pathophysiology Similar to Sudden Unexpected Death in Epilepsy?

Febrile seizures are usually considered relatively benign. Although some cases of sudden unexplained death in childhood have a history of febrile seizures, no documented case of febrile seizure-induced death has been reported. Here, we describe a child with complex febrile seizures who died suddenly and unexpectedly after a suspected seizure while in bed at night during the beginning phases of sleep. She was resuscitated and pronounced brain dead 2 days later at our regional medical center. Autopsy revealed multiorgan effects of hypoperfusion and did not reveal an underlying (precipitating) disease, injury, or toxicological cause of death. Although a seizure was not witnessed, it was suspected as the underlying cause of death based on the medical examiner and forensic pathologist (author Marcus Nashelsky) investigation, the post-resuscitation clinical findings, and multiple aspects of the clinical history. The child had a history of complex febrile seizures that had previously caused apnea and oxygen desaturation. She had two febrile seizures earlier on the same day of the fatal event. Interestingly, her mother also experienced a febrile seizure as a child, which led to respiratory arrest requiring cardiorespiratory resuscitation. This case suggests that in a child with complex febrile seizures, a seizure can induce death in a manner that is consistent with the majority of cases of sudden unexpected death in epilepsy (SUDEP). Further work is needed to better understand how and why certain individuals, with a history of epilepsy or not, die suddenly and unexpectedly from seizures. This will only occur through better understanding of the pathophysiologic mechanisms underlying epileptic and febrile seizures and death from seizures including SUDEP.

941: VENTILATOR WEANING PROTOCOL REDUCES DURATION OF VENTILATION IN A PEDIATRIC ICU

Learning Objectives: Prolonged intubation and mechanical ventilation in children can lead to higher rates of ventilator-associated events with increased morbidity and mortality. Protocol-driven ventilator weaning has been shown to reduce the duration of ventilation. Despite this, no definitive guidelines currently exist regarding ventilator weaning and extubation in children. Our objective is to determine the difference in ventilator days and PICU/hospital length of stay among mechanically ventilated PICU patients before and after the implementation of a standardized ventilator liberation protocol. Methods: We are conducting an interrupted time-series analysis of the duration of ventilation, PICU/ hospital length of stay, and extubation failure rates among mechanically ventilated patients in our PICU before (7/2012–6/2014) and after (7/2014–6/2016) the implementation of a ventilator liberation protocol. Essential elements of the protocol include daily spontaneous breathing trials in patients meeting criteria. Data is obtained from patient medical records and our local Virtual PICU Systems database. Comparisons between means and proportions were performed using the z-test and ratio of means respectively. Results: We have data for 237 patients before and 73 after implementation, as enrollment continues. There are no significant differences between groups in age, weight and gender. Cardiac admissions are higher after implementation (20% vs 36%, p=0.007). The mean duration of ventilation days decreased (5 before vs 4 after, p=0.16) although not reaching statistical significance. Extubation failure rates were not significantly different between groups. There was a significant increase in the mean PICU (10 vs 17, p=0.001) and hospital days (16 vs 26, p=0.007) before and after implementation. Conclusions: Preliminary data suggest that implementation of a ventilator liberation protocol reduces the duration of ventilation in children without a significant increase in extubation failure. An increase in PICU/hospital length of stay was observed, for which contributing factors will require further analysis.