to inappropriate and frightening scenes, such as violence, severe injury, and threatening language. Adult EDs are generally not well suited to providing a comforting or reassuring environment for children.

Evidence of Compromised Safety for Pediatric Patients

Given this potentially perilous emergency care environment, how often do medical errors occur among pediatric patients? Surprisingly, the answer to that question is unknown. In fact, there is little high-quality data on the epidemiology of medical errors in children, particularly within the emergency care system. Instead, there are a few, typically small studies demonstrating that care is compromised during several different stages of an ED visit. For example, providers often triage patients inaccurately (Selbst et al., 2004). Errors in specimen collection methods (Walsh-Kelly et al., 1997) and interpretation of radiographs are also a concern (Walsh-Kelly et al., 1995). As might be expected, children with special medical needs or those who are dependent on technology are significantly more likely to experience a medical error than other children (Slonim et al., 2003).

One of the most telling studies on the quality of pediatric care comes from a recent drill conducted in 35 EDs (including 5 trauma centers) in North Carolina. Using life-size child manakins, researchers staged “mock codes” and presented each team with a vignette describing patients’ symptoms. Nearly all of the EDs failed to stabilize seriously injured children properly during trauma simulations. Thirty-four hospitals failed to administer dextrose properly to a child in hypoglycemic shock (a life-threatening drop in blood sugar); 34 failed to warm a hypothermic child correctly; 31 failed to order proper administration of IV fluids; 24 failed to attempt or succeed at accessing a child’s bloodstream through a bone (a critical alternative for delivering fluids and medicines rapidly to sick children); and 23 failed to provide appropriate medications, monitoring equipment, and personnel needed to transport a child safely within the hospital. On the other hand, many hospitals were successful at calling appropriate individuals for assistance, performing initial airway assessment and initial bag-mask ventililation, ordering appropriate imaging tests, and conducting initial assessment of vital signs (Hunt et al., 2006).

There have been few published studies describing the nature or extent of medical errors in the EMS environment. In one research effort, however, 15 paramedics were interviewed about adverse events and near misses; all had multiple events to report. In sum, 61 events were described, 23 percent of which involved a child. The major types of errors were mistakes in clinical judgment (54 percent), errors in skill performance (21 percent), and medication errors (15 percent). Only one-third of the errors had been reported



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