Sick Children Crying for Help: Fostering Adverse Event Reports

In a Perspective, Gordon Schiff discusses the importance of appropriately analyzing adverse event reports.

studies that have quantified the extent of this failure, this waste, and these wasted opportunities, I suspect it is huge.
A key aspect of meaningfully bringing together these reports is classification of the events. Thinking critically about this step is necessary to avoid compounding empty collecting exercises with pointless taxonomy counting rituals. Analysis should breathe additional life into safety reports, rather than simply "putting them to bed." What does a vision of such breathing life look and feel like, and to what extent does the Rees et al. work give us a glimpse of it?
Two key ingredients in my view are (1) careful, timely review and contemplation of report narratives and (2) envisioning the ways such an event could happen elsewhere with an eye to error-proofing redesign. Basic quality improvement conceptual tools such as a) the "5 Whys" (digging progressively deeper by asking "why" five times to get to the root of underlying contributing causes) [9], b) distinguishing "special cause" from "common cause" (a statistical process control tool begging for more use in health care), c) minimizing "tampering" (well-meaning attempts to make changes that can introduce more variation and quality problems), and d) avoiding "suboptimization" (another improvement pitfall whereby changes are recommended or made that may help a narrowly conceived problem but create a more complex and dysfunctional system overall) need to be applied more regularly and rigorously [10,11].
With this perspective, how does the study by Rees and colleagues help move us forward? One way is by shining a light on two somewhat new or mostly untapped venues for collecting errors and adverse event reports-community pharmacies and telephone triage call centers. These two settings led the pack in reports of issues, which originated from and illustrated a number of vulnerabilities of special relevance to a pediatric population-particularly, special dosing/dispensing considerations (often requiring individualized medication compounding) and delays in recognizing septicemia. Also noteworthy was the finding that diagnostic delays had the highest burden of harm, something we have also argued and seen in malpractice cases [12]. Diagnostic errors are relatively infrequently reported to adverse event reporting systems, so finding substantial numbers here suggests this is the tip of a larger iceberg [13].
In their list of contributing causes, one item jarringly stands out both for its frequency and disharmony with a systems and just culture perspective: "failure to follow protocol" [14]. Were such reports perhaps more akin to incident reports submitted by supervisors to "write up" an employee who may have committed an error as documentation for the employee's personnel record and as a warning? To the extent these reports were grounded in a retributive workplace culture, rather than a more ideal model of frontline staff submitting reports of errors or problems that they had seen, been involved with, or personally committed, based on caring deeply about the need to share these widely to help others avoid such pitfalls, these reports fulfill a less noble and valuable function.
Lest we throw out the babies with the bathwater, we need to listen carefully to these incidents, analyze them, and act on them better (Table 1). Safety experts are debating and rethinking incident reporting on multiple continents [4,15]. Meanwhile, there is much to be learned from these reports, and the paper by Rees and colleagues just scratches the surface. Quality and learning and improvement from incident reporting need to be supported and enhanced at every step, but currently, there is a paucity of resources, responsiveness, and responsibility to do this well [16,17]. For these children and their parents, each institution should use these reports to ask and examine the questions: is this happening here; if so, how often; and how can we work at the front line and at the larger health authority level to make sure such incidents are less likely in the future [16]?