Pediatric Informatics: Computer Applications in Child Health (Health ...

394 D.C. Stockwell and A.D. Slonim
30.6 Conclusion
Incident reporting is the most commonly used method of collecting data on errors.
Its inherent selection biases prevent it from providing accurate measures of safety,
nevertheless, what it identifies can help guide improvement efforts. Electronic solutions
provide greater access to separate facilities with the possibility for learning
from other institutions. 42 To succeed in collecting data on errors, institutions must:
Create an environment conducive to reporting: The term “just culture” has
evolved out of error reporting literature and describes a work environment in
which frontline personnel feel comfortable in reporting and disclosing errors.
Promote professional accountability in reporting: A just culture recognizes that
individuals should not be held accountable for system failings over which they
have no control, but it does not tolerate conscious disregard of clear risks to
patients or gross misconduct. 40
Promote and communicate system accountability: It is important to document
results, share stories, and disseminate results. 18 Error detection is useless unless
action is taken. 41 A just culture combined with effective communication and
strategies for decreasing the likelihood of errors engages staff in identifying
them and improving the processes of care.
No individual solution is adequate. The use of complementary methods of identifying
errors increases reporting and provides better understanding of the processes of
care and greater opportunities for improving the delivery of care.
30.7 Case Study: An Adverse Event Trigger
in Hyperkalemia
During the course of treatment for a severe RSV infection and subsequent respiratory
failure, a 4 month old was given high doses of loop diuretics to improve respiratory
function and to hasten weaning from mechanical ventilation. As is common
with loop diuretics, this patient’s potassium level steadily decreased. In order to
avoid severe hypokalemia, enteral potassium supplements were initiated.
Following successful extubation, the child required fewer diuretics, but still
required them to improve respiratory function. Two days later the child was transferred
to the respiratory ward. As her respiratory function improved the diuretics
were discontinued. Via the use of an electronic adverse event trigger, it was recognized
on the third day on the ward that the child had increasing potassium levels.
This notified the adverse event coordinator to investigate the issue. Shortly after
arrival to the ward the coordinator noticed that the potassium supplements were still
being administered and the likely source of hyperkalemia. After advising the team
that this may have been an oversight, the potassium supplements were discontinued
before any adverse events secondary to hyperkalemia occurred.