Recommendations on how to minimize pediatric medical errors in the emergency department (ED) and provide safe care for children of all ages are outlined in the first joint policy on the topic from the AAP, the American College of Emergency Physicians and the Emergency Nurses Association.
The collaboration is critical since many children seek emergency care in general EDs, making it necessary for all EDs to practice patient safety principles, promote a culture of safety and adopt best practices to improve safety for all children.
The updated policy and a companion technical report Optimizing Pediatric Patient Safety in the Emergency Care Setting, from the AAP Committee on Pediatric Emergency Medicine and the other medical societies, are available at https://doi.org/10.1542/peds.2022-059673 and https://doi.org/10.1542/peds.2022-059674. They will be published in the November issue of Pediatrics.
Based on an extensive literature review, the guidance provides recommendations and resources following the frameworks of The Joint Commission, Safe & Reliable Healthcare and the Institute for Healthcare Improvement.
The policy statement and technical report also reference several policies related to pediatric ED patient safety strategies covering pediatric readiness in the ED, handoffs, patient- and family-centered care, ED crowding and medication safety.
Addressing multiple challenges
Many factors in the ED environment can make it challenging to provide safe care for critically ill and injured patients. These include overcrowding, high patient volume, high-decision density under time pressure, diagnostic uncertainty, limited knowledge of patients’ history and preexisting conditions, frequent workflow interruptions, multiple care transitions and barriers to effective communication.
To address these areas, the statements provide strategies on leadership, disaster preparedness, communication, medication safety and other topics.
Recommendations address leadership commitment to safety through adopting pediatric readiness and include the following:
- Make patient safety in the ED a priority for hospital and ED leadership.
- Ensure that all EDs have the appropriate resources (medications, equipment, policies, education) and capable staff to provide emergency care for children.
- Support the presence of a pediatric ED quality and patient safety committee or pediatric representative on the committee.
One key component of disaster preparedness for EDs is to be “pediatric ready.” Other factors include:
- ensuring disaster planning considers the unique needs of children, especially those with access and functional needs and preexisting and complex medical conditions;
- ensuring that ED staff has practiced pediatric disaster plans; and
- recognizing that the mental health needs of children experiencing disasters can extend into adulthood.
Patients with language, cultural and socioeconomic challenges are disproportionately at risk for experiencing preventable adverse events in the health care system. To address language barriers and the importance of cultural competency and humility of the health care team in addressing such disparities, the policy includes the following recommendations:
- Advocate for implicit bias training and diversify the ED workforce.
- Improve clinicians’ cultural competency/humility and awareness of their own implicit bias on the safety and quality of care of children.
- Implement shared decision-making practices and use trained language interpreter services rather than bilingual relatives or a clinician with limited proficiency in the patient’s language.
- Expand resources for beside ED interpreters, such as tele-interpreter services, which include sign language.
Guidance includes these points:
- Establish a process to ensure that body weight is measured and recorded in kilograms only to avoid inappropriate calculations.
- Advocate for the integration of ED pharmacists, when possible, within the ED team to verify the preparation, dosing, dispensing and reconciliation of medications administered in the ED, as well as drug education to the heath care team and patients.
- Recognize risk factors for medication errors during ordering, preparation and administration.
- Advocate for policies to address timely tracking, reporting and evaluation of patient safety events and for the disclosure of medication errors or unanticipated outcomes.
The policy also offers recommendations pertaining to patient- and family-centered care, cultural competency and humility, and language barriers. It calls for systematically addressing diagnostic errors, shiftwork, burnout and wellness and their impact on safety as well as psychological safety and the importance of reporting “close calls.”
There is guidance regarding ED crowding and prolonged boarding due to pediatric mental health crises and nursing and staff shortages — all of which were exacerbated during the COVID-19 pandemic. The policy suggests advocating for increased mental health services in schools; integrating mental health into pediatric primary care; increasing insurance coverage and payment for mental health care in the ED and for follow-up care; and extending access to telehealth.
Other topics involved in maximizing patient safety cover teamwork, ED shift huddles, handoffs and the role of information technology in patient care such as clinical decision support tools and their integration into the electronic health record to streamline workflows. The use of telehealth can be leveraged to enhance patient safety by connecting patients and pediatricians to remote specialist care. Telehealth also can help prevent unnecessary transfers and keep patients in rural areas connected to the health care system when in-person visits are difficult to achieve.
Dr. Joseph is a lead author of the policy statement and technical report. A member of the AAP Board of Directors and AAP Section on Emergency Medicine, she is a former member of the Committee on Pediatric Emergency Medicine.