Susan Blackburn

Use of Incident Reports by Physicians and Nurses to Document Medical Errors in Pediatric Patients

Objectives. To describe the proportion and types of medical errors that are stated to be reported via incident report systems by physicians and nurses who care for pediatric patients and to determine attitudes about potential interventions for increasing error reports. Methods. A survey on use of incident reports to document medical errors was sent to a random sample of 200 physicians and nurses at a large childrens hospital. Items on the survey included proportion of medical errors that were reported, reasons for underreporting medical errors, and attitudes about potential interventions for increasing error reports. In addition, the survey contained scenarios about hypothetical medical errors; the physicians and nurses were asked how likely they were to report each of the events described. Differences in use of incident reports for documenting medical errors between nurses and physicians were assessed with χ2 tests. Logistic regression was used to determine the association between health care profession type and likelihood of reporting medical errors. Results. A total of 140 surveys were returned, including 74 from physicians and 66 by nurses. Overall, 34.8% of respondents indicated that they had reported <20% of their perceived medical errors in the previous 12 months, and 32.6% had reported <40% of perceived errors committed by colleagues. After controlling for potentially confounding variables, nurses were significantly more likely to report ≥80% of their own medical errors than physicians (odds ratio: 2.8; 95% confidence interval: 1.3–6.0). Commonly listed reasons for underreporting included lack of certainty about what is considered an error (indicated by 40.7% of respondents) and concerns about implicating others (37%). Potential interventions that would lead to increased reporting included education about which errors should be reported (listed by 65.4% of respondents), feedback on a regular basis about the errors reported (63.8%) and about individual events (51.2%), evidence of system changes because of reports of errors (55.4%), and an electronic format for reports (44.9%). Although virtually all respondents would likely report a 10-fold overdose of morphine leading to respiratory depression in a child, only 31.7% would report an event in which a supply of breast milk is inadvertently connected to a venous catheter but is discovered before any breast milk goes into the catheter. Conclusions. Medical errors in pediatric patients are significantly underreported in incident report systems, particularly by physicians. Some types of errors are less likely to be reported than others. Information in incident reports is not a representative sample of errors committed in a childrens hospital. Specific changes in the incident report system could lead to more reporting by physicians and nurses who care for pediatric patients.

Environmental impact of the NICU on developmental outcomes

The neonate, especially the premature one, is both dependent on and vulnerable to the intensive care environment to support physiologic and neurobehavioral organization. Concerns about this environment have led to suggestions that it may be a major contributing factor in the persistent incidence of behavioral and learning problems among preterm infants. By modifying the neonatal intensive care environment to provide a more developmentally supportive milieu, we can better meet the infants physiologic and neurobehavioral needs, support the infants emerging organization, and foster growth and development.

Medication Administration Variances Before and After Implementation of Computerized Physician Order Entry in a Neonatal Intensive Care Unit

OBJECTIVE. The goal was to determine whether implementation of a computerized physician order entry system was associated with a decrease in medication administration variances in a NICU. METHODS. A prospective observational study was conducted. Research nurses recorded details of medication administrations for patients in a NICU during standardized observation periods. Details of each administration were compared with the medication order; a variance was defined as a discrepancy between the order and the medication administration. Rates of variances before and after implementation of computerized physician order entry in the NICU were compared. Specific types of and reasons for variances were also compared. RESULTS. Data on 526 medication administrations, including 254 during the pre-computerized physician order entry period and 272 after implementation of computerized physician order entry, were collected. Medication variances were detected for 19.8% of administrations during the pre-computerized physician order entry period, compared with 11.6% with computerized physician order entry (rate ratio: 0.53). Overall, administration mistakes, prescribing problems, and pharmacy problems accounted for 74% of medication variances; there were no statistically significant differences in rates for any of these specific reasons before versus after introduction of computerized physician order entry. Administration of a medication at the wrong time accounted for 53.1% of all variances. Variance rates related to giving a drug at the wrong time were significantly lower in the computerized physician order entry period than in the pre-computerized physician order entry period (rates: 6.7% and 9.9%, respectively; rate ratio: 0.53). CONCLUSIONS. Implementation of computerized physician order entry in a NICU was associated with a significant decrease in the rate of medication administration variances. However, even with the use of computerized physician order entry, variances were noted for >11% of all medication administrations, which suggests that additional methods may be needed to improve neonatal patient safety.

Problems of Preterm Infants After Discharge

Preterm infants often experience continuing health problems after discharge and have a higher rate of readmittance to the hospital during the first year. These infants also are at risk for neurodevelopmental problems, such as language, learning, and school difficulties. The continuing health and developmental problems of preterm infants creates stress for the family. Nurses caring for these infants in hospital settings must understand the problems for which preterm infants are at risk after discharge as a basis for appropriate discharge planning and teaching. A similar knowledge base will help nurses working in community settings in assessment and interventions with infants and their families after discharge.

Individual and Gender Differences Matter in Preterm Infant State Development

OBJECTIVE To further understand state development of preterm infants throughout hospitalization and the effects of selected infant characteristics on state development. DESIGN Secondary data analysis of a 2-group, experimental design study. SETTING Two nurseries in a Northwest medical center. PARTICIPANTS Ninety-seven hospitalized, medically stable, preterm infants. Fifty-one subjects were females. METHODS Two hundred and eighty-five real-time video recordings of infants performed during 4 hour interfeeding intervals. Sleep-wake states were coded at 15 second intervals. RESULTS Active sleep was the dominant state across postmenstrual ages. Although not statistically significant, preterm infants showed developmental changes in state organization with increased quiet sleep, drowsy, and awake, decreased active sleep, and more defined and less diffuse states over age. A significant gender effect was found, with males having less active sleep (p=.012), more drowsy (p=.03), more awake (p=.043), less defined (p=.002), and more diffuse (p=.001) states compared with females. CONCLUSION The predominance of active sleep during the preterm period reflects level of brain maturation. The results emphasize individual variations in state organization influenced by endogenous and environmental factors. Gender differences are potential sources of individual variation.

State of the science: achievements and challenges across the spectrum of care for preterm infants.

The spectrum of care for preterm infants includes the perinatal and immediate neonatal periods, the initial hospitalization period including neonatal intensive care, transition to discharge, and from discharge through the first year of life. Care issues are sometimes lifelong. Advances and achievements of the past 20 years, particularly during the perinatal period and in neonatal intensive care, have resulted in significant increases in survivability of even the smallest and least mature infants. Challenges remain, particularly in establishing evidence-based standards of nursing practice in areas such as transition to oral feedings, breastfeeding in the intensive-care nursery, and developmentally based care, and in reducing short- and long-term morbidities in children born prematurely. This article illustrates achievements and challenges across the spectrum of care for preterm infants in the 1st year of life.

Interventions that Enhance Breastfeeding Initiation, Duration, and Exclusivity: A Systematic Review

Objective:The purpose of this review was to evaluate breastfeeding interventions trialed to date and recommend directions for future needs in breastfeeding research. Methods:A literature review was conducted using PubMed, CINAHL Plus, and PsycINFO databases to identify studies that evaluated efficacy or effectiveness of breastfeeding interventions on breastfeeding initiation, duration, or exclusivity as a primary, secondary, or tertiary outcome. Combinations of search terms included breastfeeding, feeding behavior, prenatal/patient education, health promotion, social support, perinatal/prenatal/intrapartum/postnatal care, and postpartum period. Results:Six studies were included in this review, using PRISMA guidelines. Acquisition of knowledge and skills, emotional support by healthcare providers, and self-efficacy over maternal confidence in her ability to breastfeed were factors the intervention studies relied on to affect breastfeeding practices. Although these factors were addressed in the studies, breastfeeding mothers had difficulty transferring what they gained from interventions into their real-life breastfeeding practices as evidenced by the highest drop-off rate of exclusive breastfeeding in the early postpartum. Conclusions:There were conceptual limitations to the reviewed studies: (1) lack of understanding of maternal perception of infant behavior and (2) perceived insufficient milk as a remaining primary reason for breastfeeding discontinuation. There were methodological limitations: (1) lack of theory-based interventions and (2) lack of intervention fidelity. Future studies involving breastfeeding should focus on the causes of the problems driven by theory-based interventions integrated with intervention fidelity.

Neonatal thermal care, part III: The effect of infant position and temperature probe placement.

Purpose: Accurate management of infant temperature requires appropriate placement of temperature monitoring probes. Currently, there is a lack of consensus regarding placement of skin temperature probes and the effect on temperature monitoring of the infant’s lying on the probe. The objective of this study was to compare abdomen and back skin temperatures when infants were positioned supine and prone. Design: A quasi-experimental design was used to randomize infants to prone or supine position. Infant back, abdomen, and axillary temperatures were measured at oneminute intervals with small disposable thermocouples over a one-hour period. Sample: Twenty-three infants, weight 820–2,400 gm, gestational age 27–37 weeks, postnatal age three to ten days. Main Outcome Variable: Gradient between abdomen and back temperature. Results: Both mean abdomen and mean back temperatures differed significantly by position (t-test, p = .003 and .028, respectively). Weight and postnatal age did not have an effect on the mean difference between abdomen and back temperature. Results indicate that probe placement and infant positioning are important factors altering measurement of skin temperature.

Neonatal thermal care, part II: Microbial growth under temperature probe covers.

Purpose: To determine if temperature probe covers contribute to nosocomial infections by providing an environment for skin microbe colonization. Design: Descriptive, comparative design with infants randomized into two groups: foam probe cover and hydrogel probe cover. Skin cultures were obtained 72 hours after cover placement. Bacterial growth was quantified after 24 and 48 hours. Skin integrity was assessed using visual irritations scores (VIS) every 5 minutes for 30 minutes following cover removal. ANOVA and ANOVA-RM were used to compare amounts of microbes and VIS scores between groups. Sample: Twenty-six medically stable infants, 29 to 34 weeks gestational age, less than 10 days postbirth, and in an incubator. Main Outcome Variable: Microbial growth and VIS. Results: There were no statistically significant differences in microbial growth and VIS scores between groups (p >.05). Clinical significance was noted in VIS scores. Infants who had foam covers had more sustained irritation scores.

Neonatal thermal care, part I: Survey of temperature probe practices.

Purpose: To determine nurses’ practices regarding skin temperature probes. Design: Data were collected using an anonymous questionnaire, which was returned by mail. Questionnaires were distributed by volunteer neonatal nurses. Items included frequency of probe change, position of probe, use of probes in skin and air servocontrolled incubators and radiant warmers, as well as demographic data. Sample: Eighty-three neonatal nurses. Results: Nurses reported that skin servocontrolled incubators are used widely, but generally only for infants less than 28 weeks gestational age; a high proportion of respondents reported using continuous monitoring of skin temperature in air servocontrol incubators. Although most nurses reported positioning infants to prevent their lying on the probe, 21 percent reported using the same probe site regardless of infant position. Routine changing of the probe cover was reported by a number of nurses. Practices were influenced by individual knowledge, beliefs, and experience as well as by unit protocols, which varied widely.