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CS Mott Children’s Hospital: Patient Safety Issues

Chris J. Dickinson, M.D.

Chief Medical Officer

Children’s & Women’s

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CS Mott Children’s Hospital

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CS Mott Children’s Hospital

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CS Mott Background - I

•  Part of University of Michigan Health

•  Single campus – Mott attached to adult University Hospital – Medical and Nursing Schools on same campus– School of Public Health across the street

•  Located in Ann Arbor, Michigan – Population 116,000 without students– Population almost doubles on football Saturdays– 45 miles from Detroit

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CS Mott Facts - II

•  234 pediatric beds new building 5 years old – 128 acute care– 60 ICU– 46 neonatal ICU

•  20 OR’s – IR, MR/OR, 3 cardiac OR’s

•  Emergency Department – 36 beds & 25,000 visits/yr

•  Attached out-patient space with infusion area

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Background-III

•  50 women’s obstetric beds located in the Von Voigtlander Women’s Hospital – 9th floor same building

•  NICU on 8th floor– 4,800 births/year– Useful for critically ill mothers or babies

•  Exit procedures where the baby is delivered by c-section but placenta is not

•  Baby then placed on ECMO and cord cut•  Placenta delivered and maternal wound closed

– OB clinics and fetal diagnostic center adjacent

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Super Heroes

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Significanteventsorinjuries

SlideconceptadaptedfromJamesReason,ManagingtheRisksofOrganiza2onalAccidents,1997

SuperHeroesinMedSafety Joyce

Somepoten7alerrors:•  Medica7onSelec7on•  Concentra7on•  Route•  Interac7onorAllergy

Wri2ngasinglemedica2onorder

AnnuallyInMo@weadminister~1.2milliondrugdoses

Resident

Nurse Med Manager

Pharmacist

If together we are 99.9% accurate

3-4 errors reach the patient every day

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Root Cause Analysis of Med Errors

•  Many medications used in pediatrics are not commercially available as liquids and must be compounded

•  Prescribers have no control over the concentration of any compounded medication – Pharmacies can and do compound at many different

concentrations for a single drug– Problem when patients arrive from outside and

family says they give 1 tsp of med•  There is no single “gold-standard” recipes for

compounding which can lead to: – Concentration errors– Stability concerns

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Compounded Meds

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Solution

•  Standards developed

•  Website created – mipedscompounds.org – Includes standards, recipes, references

• 

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Pediatric Safety Issues

•  Often similar to adult issues but there are significant differences – Children’s safety should be informed by but not

driven by adult issues

•  There is a need for better pediatric specific quality metrics for children’s hospitals to focus on

•  Children’s Hospitals will need to work together (Solutions for Patient Safety) – Share data and ideas