Patient safety problems in adolescent medical care

Article Outline

• Abstract
• Methods
  • Adverse event
  • Preventable adverse event
  • Patient safety problems/critical incidents
  • Population-based study
  • Sample
  • Medical record review protocol
  • Analysis
  • Critical incident analysis
  • Sample
  • Interview protocol
  • Analysis
• Results
  • Population-based study
  • Critical incident analysis
  • Harm related to patient safety problems in adolescent medical care
  • Problem types
  • Adolescent-specific factors
  • Preventive mechanisms for patient safety events in adolescents
• Discussion
  • Limitations and Strengths
• Conclusion
• Acknowledgments
• References
• Copyright

Abstract 

Purpose

This study estimates the annual incidence and describes the nature, types, and contributing factors involved in patient safety problems in adolescent medical care.

Methods

This study uses data from the population-based Colorado and Utah Medical Practice Study to describe the incidence of hospital-based adverse events and preventable adverse events in adolescents and “critical incidence analysis” data reported by pediatric clinicians to elucidate the nature, types, and contributing factors in adolescent patient safety problems.

Results

The incidence of adverse events in adolescents in the Colorado and Utah Medical Practice Study was 2.74 (CI 95% = 2.62–2.86), significantly higher than all other age groups of children. The incidence of preventable adverse events in adolescents was 0.95 (CI 95% = 0.65–1.25), significantly higher than that of children 1–12 years old, but not significantly different than infants. Diagnostic events were most common, followed by medication events. Services associated with the highest frequency of events were pharmacy and Family Practice. In the critical incident analysis, adolescent-specific factors contributed to 54.8% of the described patient safety problems. Discomfort with adolescents, a factor not described for other age groups of children, contributed to 17% of the adolescent patient safety problems.

Conclusions

Adolescents experience relatively high rates of patient safety problems compared with other age groups of children. Adolescents represent a defined population with a patient safety risk profile that differs from adults and younger children. The substantial contribution of adolescent-specific factors suggests that patient safety improvements, to be effective, should address adolescent-specific risks.

Keywords:  Medical errors , Medication errors , Diagnostic errors , Surgery errors , Adolescent , Child , Pediatric , Adverse events , Preventable adverse events

Medical errors and related injuries lead to unnecessary harm and costs and have become an important focus in health care after the Institute of Medicine report “To Err Is Human” [1]. Significant improvements in the understanding of patient safety problems and the development of interventions aimed at patient safety improvement have occurred in adult medical care, however there is limited understanding of these issues for medical care delivered to children and youth [2], [3]. Three studies have investigated patient safety in hospital-based pediatric medical care [4], [5], [6]. All of these studies, using different data sources and methodologies, found that the epidemiology of patient safety problems was different between children and adults. However, we are unaware of any study that has focused specifically on patient safety problems in adolescent medical care.

Adolescents present unique challenges to clinicians and to the health care system [7]. Their morphological, physiological, and social characteristics differ from those of younger children, as well as from those of adults. The medical care needs of adolescents also vary from those of younger children (e.g., reproductive health, sexually transmitted disease) and from adults. Data from the 2000 Health Care Cost and Utilization Project (HCUP) suggest that there are potentially meaningful differences in the diagnostic and medical care needs of adolescents compared with other age groups. The most common discharge diagnoses for adolescents were categories related to labor and delivery, psychosis, and depression, whereas the most frequent discharge diagnoses for school-age children were pulmonary conditions; and for infants, birth, respiratory, and digestive diagnoses [8]. In nonelderly adults, the most common discharge diagnoses include labor and delivery and cardiac-related categories, as well as mental health diagnoses [9].

Most ambulatory medical care of adolescents in the United States is not performed by adolescent medicine physicians, but rather by general pediatricians and adult primary care physicians [10]. Likewise, hospital-based medical care of adolescents takes place in either pediatric or adult medical care settings. Adolescent medical care, therefore, often represents a departure from routine practice for both physician and nursing clinicians, in settings that are not usually customized for adolescent patient needs. These factors may increase an adolescent’s risk of experiencing an error or an adverse event.

This study combines two data sources. First, we analyzed data from the population-based Colorado and Utah Medical Practice Study to describe the incidence of hospital-based adverse events and preventable adverse events in adolescents. Then, we analyzed “critical incidence analysis” data of clinician descriptions of adolescent patient safety problems to elucidate the nature, types, and contributing factors and to offer possible solutions for patient safety problems in adolescents.

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Methods 

The definitions used in this study include:

Adverse event 

Injury caused by medical intervention or management, rather than the disease process, which either prolonged the hospital stay or caused disability at discharge [11].

Preventable adverse event 

An adverse event, where there was enough information currently available to have prevented the event using currently accepted practices [12].

Patient safety problems/critical incidents 

Medical care situations in which something did not go quite right, something did not go as planned in the medical care of a child [1].

Definitions of the problem types are shown in Figure 1.

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• Fig. 1. 

  Definitions of problems types.

Population-based study 

The Colorado and Utah Medical Practice Study collected data on adverse events and preventable adverse events through retrospective medical record review of a representative sample of all hospital discharge records in Colorado and Utah in 1992 [11]. The sampling methodology for the Colorado and Utah Medical Practice study was designed to enable the estimation of population-based epidemiological results. All hospitals in Colorado and Utah were characterized by size, location (urban, rural), teaching status, and ownership (for-profit, non-profit, government). Strata were then created representing all possible combinations of these characteristics and each hospital was placed into an appropriate strata. At least one hospital from each stratum was invited to participate in each state and no invited hospital refused. Veteran’s Administration, psychiatric, rehabilitation, and drug and alcohol diagnosis-related groups and hospitals were excluded [11].

Sample 

A random sample of hospital discharge records from 1992 was selected from the participating hospitals in Utah and Colorado, resulting in a sample of 5000 records from Utah and 10,000 records from Colorado. The number of records sampled at each hospital was proportional to the number of discharges at each hospital relative to the total discharges of all hospitals in the study [11].

A total of 14,700 medical records were reviewed, of which 3719 were pediatric records (birth–20 years old). Of the pediatric records, 879 were adolescent records (13–20 years old). Adverse events were classified into mutually exclusive types depicting the aspect of medicine (medication, surgical, etc.), the “covering” service (pediatrics, family practice, obstetrics, etc.), and the location in which the event occurred (patient’s room, operating room, nursery, etc.). These criteria and the criteria used to determine an adverse event were specifically designed to be applicable to all hospitalized patients.

Medical record review protocol 

Trained nurse reviewers screened the sampled records to identify those with one or more of 18 standardized criteria associated with an adverse event (Was there hospital-incurred trauma? Was there an adverse drug event? Was treatment or operation performed because of damage to organ or organ systems subsequent to an invasive procedure?). Physicians then reviewed the records that met the screening criteria. The physician reviewers, using a 6-point confidence scale, graded their confidence that an adverse event had occurred. A score of 4 or higher was required for the event to be classified as an “adverse event.” The Kappa statistic for inter-rater reliability of the classifications indicated 79% agreement (κ = .4) [11]. Two study investigators, in the original Colorado and Utah Medical Practice study, then determined the preventability of the event, again using a 6-point scale, with a score of 4 or higher required for the event to be classified as preventable [11]. The classifications, determined in the original Colorado and Utah Medical Practice study, were used in this study.

Analysis 

Comparative incidence rates, by age group, of adverse and preventable adverse events were estimated. Weighted population estimates are presented. Weights were calculated by dividing the number of discharges in the stratum by the total number of records for each of the sampled hospitals.

Critical incident analysis 

Data were also gathered using the “critical incident analysis” technique [12], which has been widely applied to the study of human factors and used for the assessment of factors associated with system failure risks. The critical incident analysis technique can provide data similar to that gathered in safety studies in other high-risk industries and can provide the details about patient safety problems in adolescent medicine, to permit an understanding of the underlying risks and mechanisms and offer recommendations for preventive improvements.

This technique has been increasingly applied in medicine [13], [14]. For example, Coté et al applied this technique to a systematic review of sedation medications and their related risks in children [14].

Sample 

Hospital-based pediatric clinicians (attending physicians, residents, nurses, and pharmacists), from an urban children’s hospital were asked to participate in in-person, audio-taped interviews to describe clinical situations “in which something did not go quite right or did not go as planned in the medical care of a child.” Subjects were randomly selected from personnel lists of hospital and medical school departments from different units (e.g., medical, surgical, PICU, ED) and specialties (e.g., neurology, surgery, cardiology). Selected subjects were mailed a letter inviting them to participate and then were called to schedule an interview. The study complied with all features of Peer Review law and offered complete confidentiality protection for all participating subjects by removing all identifying information.

Interview protocol 

A standardized interview protocol was used to identify patient safety events in which the clinician had participated or had observed within the last six months. In addition, clinicians were asked to provide demographic and detailed clinical data about the patients who were involved in these events before and after the occurrence of the event. Clinicians were asked to assess the level of harm that resulted from the event on a scale of 0 to 9 (0 = no harm or near miss, 1 = emotional harm, 2 = insignificant physical harm, 3 = minor temporary harm, 4 = major temporary harm, 5 = minor permanent harm, 6 = significant permanent harm, 7 = major harm, 8 = grave harm, 9 = death). Clinicians were also asked to recommend potential preventive mechanisms. One investigator (D.W.) conducted all of the interviews. The study complied with all features of Peer Review law and offered complete confidentiality protection for all participating subjects by removing all identifying information.

Analysis 

Through a text-based constant comparative analysis of the transcribed interview data, a classification system was inductively developed for the types of problems that occur in pediatric patient safety problems and potential preventive mechanisms for these problems [15]. Factors related to theoretical vulnerabilities to the occurrence of errors and adverse events, in medical care, in children of all ages, were identified through review of the literature [16]. These factors were then tested to determine the overall extent to which the child-specific factors contributed to the occurrence of the identified patient safety problems and to understand the contribution of each of the specific individual factors to events in all age groups of children. Three reviewers (2 pediatricians and 1 patient safety researcher) independently classified each of the patient safety events into the mutually exclusive categories. Independent classification of problem types resulted in 88.1% agreement among the investigators, 78.4% agreement in classification of the contributing adolescent specific factors, and 88.5% agreement in the classification of the recommended preventive mechanisms. Discrepancies in classification were resolved through a second review to reach consensus. Descriptive statistics were used to describe the relative frequencies of the patient safety problems and contributing factors.

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Results 

Population-based study 

As shown in Table 1, the annual incidence rate of adverse events in adolescent patients was 2.74 per 100 adolescent patient discharges (95% CI = 2.62–2.86) and the annual incidence rate of preventable adverse events in adolescent patients was 0.95 per 100 adolescent discharges (95% CI = 0.65–1.25). In comparison, the rate of adverse events and preventable adverse events in infants (birth through 1 year of age) were 0.63 per 100 infant discharges (95% CI = 0.43–0.85) and 0.53 per 100 discharges (95% CI = 0.33–0.73), respectively; for children 1 through 12 years old, these rates were 0.92 per 100 discharges (95% CI = 0.62–1.22) and 0.22 per 100 child discharges (95% CI = 0.12–0.32), respectively; and in nonelderly adults (21–65 years of age) these rates were 3.84 per 100 nonelderly adult discharges (95% CI = 3.79–3.89) and 1.50 per 100 discharges (95% CI = 1.20–1.80), respectively.

Table 1. Rates of adverse events and preventable adverse events per 100 discharges by age group using the Colorado and Utah Medical Practice Study data

Age group	Adverse event rate (CI 95%)	Preventable adverse event rate (CI 95%)	Total number of discharges in the states of Colorado and Utah
< 1 Year	.63(.43–.85)	.53(.33–.73)	96,073
1–12	.92(.62–1.22)	.22(.12–.32)	23,122
13–21	2.74(2.62–2.86)	.95(.65–1.25)	25,247
21–65	3.84(3.79–3.89)	1.50(1.20–1.80)	279,497

Adolescents experience a significantly higher rate of adverse events than other age groups of children but a lower adverse event rate than adults. The rate of preventable adverse events in adolescents was significantly higher than those experienced by younger children but was not significantly different from that of infants or that of adults. Infants had the highest proportion of adverse events that were determined to be preventable. Adults had a high rate of adverse events but a smaller proportion of these events were determined to be preventable. The high rate of preventable adverse events among adolescents was related to both the high rate of adverse events and the relatively high proportion of those events determined to be preventable.

Diagnostic adverse events and preventable adverse events were the most common event type followed by medication-related events (Table 2). Medication- and diagnostic-related preventable adverse events together represented nearly three-quarters of the identified preventable adverse events. Services associated with the highest frequency of both adverse events and preventable adverse events were pharmacy and Family Practice. Preventable adverse events in pharmacy and in Family Practice represented more than half of the identified preventable adverse events. The locations associated with the highest frequency of adverse events and preventable adverse events in adolescents were the pharmacy followed by the physician’s office (Table 2). Despite the hospital-based nature of this study, 30.8% of the preventable adverse events occurred before hospitalization in ambulatory care settings. The mean harm associated with adverse events in adolescents was 3.0. The mean harm associated with preventable adverse events in adolescents was 3.3.

Table 2. Population distribution of adverse event and preventable adverse event by type, service and location in adolescents from the Colorado and Utah Medical Practice Study data

Event type	Adverse events		Preventable adverse events
	n	(%)	n	(%)
Population total	1204	100.0	685	5.3
Diagnostic	314	26.1	256	37.4
Medication	311	25.8	253	36.9
Pregnancy and delivery	294	25.8	103	15.0
Surgical procedures and nonsurgical procedures	185	15.4	40	5.8
Therapeutic	33	2.7	33	4.8
Fracture	67	5.6	0	0.0
Service
Pharmacy	253	21.0	253	36.9
Family practice	278	23.1	198	36.9
Obstetrics	298	24.8	116	16.9
General surgery	118	9.8	58	8.2
Gynecology	27	2.2	27	3.9
Orthopedic surgery	159	13.2	20	2.9
Endocrinology	13	1.1	13	1.9
Thoracic surgery	58	4.8	0	0.0
Location
Pharmacy	253	21.0	253	36.9
Ambulatory care/physicians office	269	21.3	211	30.8
Operating room	285	23.7	130	19.0
Patient’s room	91	7.6	91	6.4
Labor and delivery	205	17.0	21	6.4
Intensive care unit	58	4.8	0	0.0
Home	44	5.3	0	0.0

Reproductive health care is an aspect of medical care that distinguishes adolescents from other age groups of children. To assess whether events related to reproductive health accounted for the significant differences in adverse and preventable adverse events rates, we estimated the rates after removing events related to pregnancy and delivery. When pregnancy and delivery events were removed from the analysis, the rate of adverse events in adolescents was 2.17 (95% CI = 2.06–2.28), which remained significantly higher than the rates for infants and children aged 1–12 years. The preventable adverse event rate for adolescents was 0.8 (95% CI = 0.6–1.0), which was still significantly higher than the rate for children aged 1–12 years but higher than the rate for infants.

Critical incident analysis 

Thirty-five pediatric clinicians (attending physicians, resident physicians, nurses, pharmacists) from different units (medical, surgical, PICU, ED, etc.) and specialties (neurology, surgery, cardiology, etc.) described 167 independent pediatric patient safety problems. All selected clinicians participated. Thirty-one of the patient safety problems (19%) occurred in the medical care of an adolescent patient.

Harm related to patient safety problems in adolescent medical care 

The mean level of harm assessed by clinicians associated with patient safety problems in adolescent medical care was 2.8. No harm (21%) and minor permanent harm (21%) were the most frequent levels of harm. Major permanent and significant permanent disabilities were assessed in 10% of the problems. Two adolescent deaths were related to the described patient safety event.

Problem types 

The most frequently described problem type was problematic execution, followed by problematic decisions, and problematic communication (Table 3). Problematic decisions, however, led to the greatest mean assessment of harm. Problematic decisions represented a higher proportion of adolescent patient safety problems when compared with patient safety problems that occurred in other age groups of children.

Table 3. Distribution of problem types in adolescent medical care and related harm

Problems occurred in many different locations: physician’s office (25.8%), patient’s hospital room (22.6%), operating room or catheterization laboratory (22.6%), pediatric intensive care unit (16.1%), Emergency Department (6.5%), medical imaging (3.2%), and hospital lounge (3.2%). Many different services were involved in the occurrence of the described patient safety problems: pediatric surgical services including transplant, orthopedics and urology, (19.4%), general pediatrics (12.9%), pediatric nephrology (12.9%), pediatric cardiology (9.7%), pediatric hematology/oncology (9.7%), adolescent medicine (9.7%), pediatric intensive care (6.5%), pediatric emergency medicine (6.5%), pediatric infectious diseases (6.5%), pediatric neurology (3.2%) and pediatric pulmonology (3.2%).

Adolescent-specific factors 

Adolescent-specific factors, shown in Table 4, contributed to just over half (54.8%) of the described patient safety problems. Although physical characteristics and physiological development of adolescents contributed most frequently to the occurrence of patient safety problems, the greatest mean harm was related to problems in which cognitive, social, or emotional development and minors’ legal status contributed directly to the occurrence of the problem. Additionally, “discomfort” in caring for an adolescent patient, not described for any other age group of children, was described as contributing to 17% of the adolescent patient safety problems. Table 5 shows examples in which adolescent-specific factors were described as contributing to the occurrence of the patient safety problems in the care of adolescent patients.

Table 4. Distribution of adolescent specific factors that contribute to patient safety problems in adolescent medical care and related harm

Table 5. Examples of adolescent-specific factors

Preventive mechanisms for patient safety events in adolescents 

Clinicians were asked to recommend mechanisms for preventing the described patient safety problems. As shown in Figure 2, a majority of the recommendations included one of three preventive mechanisms: training, improved clinician communication, and staffing resources (e.g., sufficient staff, appropriate staffing). The recommendation for training included adding content to, and improving initial and continuing training of clinicians. Additional elements of training included providing adolescent-specific medical knowledge or skills, reinforcing procedures or policies; and providing clinician certification for the acquisition of adolescent-specific skills or knowledge.

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• Fig. 2. 

  Frequency of clinician-recommended patient safety improvement strategies to address patient safety events in adolescent medical care.

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Discussion 

Adolescents represent approximately 9% of annual hospital discharges in the United States and approximately 4% of total hospital costs. As a population, adolescents do not account for a large proportion of either health care utilization or costs [8]. This may explain why patient safety in adolescent medical care has not, to date, been a particular focus of study. However, the findings from this study demonstrate that adolescents have the highest rate of adverse events among children and have a significantly higher rate of preventable adverse events than children aged 1 through 12 years of age. This finding is consistent with a study by Miller et al, which found a significantly greater likelihood of patient safety indicators (PSIs) to be associated with adolescent age ranges (10–14 years and 15–19 years) than with other age groups of children [5].

Several factors may contribute to this finding. First, most adolescent patients in the United States receive hospital-based medical care in either pediatric or adult medical settings. In these settings, adolescent patients represent a change from the routine patient population and most likely also represent a departure from routine practice in the care setting. Thus, adolescents experience a potentially greater risk for patient safety problems. Because adolescents are not a substantial part of the patient population in either pediatric or general medical facilities, standard systems are not generally designed and put into practice for adolescent patient needs and clinicians also may not be adequately trained to care for adolescents.

Second, the reproductive health care needs and capacities of adolescents also distinguish them from younger age groups. However, this study found that the rate of adverse events among adolescents remained significantly different from those of infants and children (1–12 years) after removing pregnancy and delivery-related events from the analysis.

Finally, adolescents may have less of the physiological resilience that characterizes younger children and, thus, their rates of adverse events and preventable adverse events may more closely approximate those of adults. In other words, adolescents may have adverse event and preventable adverse event rates that are more like those of adults because they are physically and physiologically more like adults. However, it is unlikely that this represents the full explanation, given the high proportion of patient safety events with contributing adolescent-specific factors.

The findings from this study suggest that the areas most commonly leading to patient safety risk in adolescents include processes associated with making diagnoses, or involve pharmacy and Family Practice settings. Additionally, we found that in the medical care of adolescents, problematic execution was most common and led to the greatest mean harm. Further research is needed to better understand the nature of the specific risks for adolescents in these medical care contexts. Although the population-based study is based on hospital discharges, nearly one-third of the identified preventable adverse events occurred in ambulatory care settings before the hospitalization.

Adolescent-specific factors were related to more than half of the patient safety problems described. To reduce patient safety risk for adolescents, such factors will need to be considered in the redesign of systems to deliver medical care to adolescents.

Many adolescents experience social and developmental stresses that can affect their interactions with the health care system [17], [18]. Although adolescents may physically appear adult-like, they may often respond to medical care interactions in a manner quite unlike an adult. In adolescence, peer relationships become highly significant and relationships with adults, including parents and clinicians, can be strained. The increased inclination toward personal privacy and the relatively common adolescent concerns about body image can contribute to making the performance of a history and physical examination of some adolescents more challenging [19]. Despite American Academy of Pediatrics (AAP), American Academy of Family Practice (AAFP), and American Medical Association (AMA) guidelines supporting confidential screening and counseling for adolescents, nearly half of all youth had never had a private, one-on-one discussion alone with their clinician [20]. Adolescence is also a time when clinicians encourage a shift in responsibility for making social and health decisions, from the parent to the adolescent, yet the quality of care delivered, the laws governing confidentiality, and the age at which adolescents are considered to be of majority for certain adolescent-related health decisions varies significantly by state. This variation poses yet another challenge for clinicians who are not specialized in adolescent medicine.

Training was the most commonly recommended intervention to prevent patient safety problems in adolescent medical care. Given that most clinicians providing medical care to adolescents have received relatively little adolescent-specific training, it is not surprising that additional training has been recommended. Training in adolescent medicine is included in current Family Practice residency requirements and was added to pediatric residency training requirements in 2001. Increasing the availability of adolescent medicine “Continuing Medical Education” may address some of these training needs for clinicians.

Limitations and Strengths 

This study has several limitations. The population-based study results are based on retrospective chart review and on clinician assessments regarding the occurrence of an adverse event and of the preventability of the event. The clinicians involved in the determination were Internal Medicine and Family Practice physicians and were not particularly focused on adolescent medicine or any other specialty of medicine. Additionally, the small number of identified events limits the extent and precision of the analysis and does not reliably permit the estimation of distributions by different adolescent age groups.

The critical incident analysis study relies on clinician selection of problems described and therefore, may be subject to clinician bias in the selection of reported patient safety events. Although the findings can provide detailed information about varied patient safety problems including rare, yet potentially harmful events, this methodology cannot provide an estimation of rates of these events.

Lastly, the differences in methods used in the two parts of the study must be considered in the interpretation of the conclusions. The data for the population-based study were gathered about patients who were not a part of the critical incidence analysis.

Nonetheless, this study is the first that we are aware of that provides population-based estimates of adverse and preventable adverse event rates for adolescents and has the ability to classify problem types, to assess adolescent-specific factors, and to offer recommendations for interventions to reduce adolescent patient safety problems. By combining quantitative and qualitative data, we combined the best data currently available about patient safety problems experienced by adolescents and identified several keys areas for future research about adolescent patient safety.

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Conclusion 

The findings from this study suggest that adolescents have a patient safety risk profile that differs from that of adults and younger children. Given that adolescent-specific factors contributed actively to over half of the patient safety problems in this study, patient safety improvements and redesign efforts must take into account and address adolescent-specific risks to be effective.

This study also demonstrates that there is still much more to understand about specific patient safety issues in adolescents. Future research is needed to better define the nature of these specific risks. Attempts should be made to understand the extent to which the higher rates of adverse events and preventable adverse events in adolescent medical care are owing to adolescent-specific vulnerabilities, the settings in which they receive medical care, or whether adolescents have less of the physical and physiological resilience of younger children, or some combination of each. At a minimum, consideration should be given to increasing the amount of adolescent medical care training (including both knowledge and skill acquisition) in the general medical training of all clinicians who provide health care to adolescents.

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Acknowledgments 

We thank Joe Feinglass, Ph.D. and Saul Weiner, M.D. for their helpful comments during the development of this work. Research for this paper was supported in part by a grant from the Children’s Memorial Institute for Evaluation and Research of Children’s Memorial Hospital Chicago, IL and done in part while the first author was a National Research Service Award postdoctoral fellow at the Institute for Health Services Research and Policy Studies under an institutional award from the Agency for Healthcare Research and Quality.

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