Medical Errors Are More Common In Complex Cases. Reported medical errors affect fewer than 3 percent of hospitalized children nationwide but are more common in complex cases like last month’s heart-lung transplant that ended with a teenager’s death, a study suggests.
Jesica Santillan died Feb. 22 after receiving a heart-lung transplant from a donor with the wrong blood type. Doctors at Duke University Medical Center acknowledged the error, but a second transplant failed to save the girl.
The study lacked specifics about cases it analyzed, but specialists say errors involving mismatched blood types in transplants are rare.
It found errors occurred in about 11 percent of cases involving children with complex medical conditions, which include organ transplants and cancer. Results are based on data from 1988, 1991, 1994 and 1997. About 900 hospitals nationwide and more than 1 million children each year were involved.
The researchers said the true number of mistakes affecting hospitalized children is likely higher because they “are undoubtedly underreported in administrative databases.”
Their report appears in the March edition of Pediatrics, being published Monday. Dr. Anthony Slonim of Children’s National Medical Center in Washington, D.C., led the research.
Slonim said the study will help doctors “target a group of children who may be at particular risk for medical errors during hospitalization and create systems that will provide safeguards against their occurrence.”
Most Errors Were Related To Complications
The study found most errors were related to “procedural complications,” including mechanical problems with devices such as breathing tubes or ventilators.
Deaths were more common among children subjected to errors than among those without, but co-author Dr. Jill Joseph, also at Children’s, said the researchers don’t know if any of the deaths were caused by error. She also said it’s uncertain how many of the errors might have been preventable.
While the overall error rates increased slightly during the study, they appeared to level off at the end. Whether they have remained stable since is unknown, Joseph said.
Dr. Dan Stryer of the government’s Agency for Healthcare Research and Quality, who was not involved in the research, called the rates “unacceptable.”
“We have to continue working to try to eliminate errors,” Stryer said.
He speculated that rates might have risen slightly since the study because hospitalized children tend to be much sicker than they were five years ago, and thus “more at risk for adverse events.”
But Dr. Douglas Moodie, pediatrics chairman at Ochsner Clinic Foundation, said awareness of medical errors and hospitals’ efforts to reduce them has increased dramatically in recent years and likely has kept the rate in check.
Stryer noted that a highly publicized Institute of Medicine report in 1999 that increased awareness of medical mistakes referred only to adults, and he praised the new report for providing needed information on children.