Presenters: Julie J. Mohr, MSPH, PhD
Institution: The University of Chicago, Chicago, IL
Co-Author: Carole Lannon, MD, MPH
Introduction: Approximately 70 percent of pediatric care occurs in ambulatory settings. Research has documented errors in inpatient settings, yet there has been little research on medical errors and patient harm in pediatric ambulatory settings. The LEAP study – Learning from Errors in Ambulatory Pediatrics – proposed to develop and implement a secure, web-based survey for reporting errors in pediatric ambulatory settings and identify types and range of errors in children’s ambulatory care.
Methods: Data collection was pilot tested in 5 pediatric practices in April 2003. Three months of data collection began in June with 20 pediatric practices.
Results: Final results will be available for the National Conference in September, but during the pilot phase, administrative errors and medication errors were most frequently reported. For example, one administrative error was "Test results weren’t received by the parent in the mail. When the parent called to ask, we found that they had listed two addresses, and I had sent it to the wrong address." One reported medication error was "Patient was prescribed an antibiotic that patient was known allergic. Antibiotic was filled but problem was noted prior to giving medication to patient." Physicians reported errors, yet various members of the care team (parents, nurses, transcriptionists, receptionists, lab techs, and pharmacists) discovered the errors. This suggests that everyone has a role preventing errors from reaching the child.
Only one reported error resulted in harm to the patient, i.e., all other reported errors were caught and corrected before reaching the patient or the error reached the patient, but did not result in harm.
Discussion: Information learned from this study will be instrumental to the subsequent design of interventions to reduce errors and improve patient safety for children.
Funding: AHRQ
Collaborators: The University of North Carolina; The University of Chicago; and The American Academy of Pediatrics’ Pediatric Research in Office Settings Network
Pediatric Care in Ambulatory Settings
