Speaker Presentation from U.S. News Healthcare of Tomorrow leadership summit, November 2-4, 2016 in Washington, DC. Find out more about this forum at www.usnewshot.com.

1. 1
CS Mott Children’s Hospital:
Patient Safety Issues
Chris J. Dickinson, M.D.
Chief Medical Officer
Children’s & Women’s

2. 2
CS Mott Children’s Hospital

3. 3
CS Mott Children’s Hospital

4. 4
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

5. 5
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

6. 6
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

7. 7
Super Heroes

8. 8
Significant
events or
injuries
Slide concept adapted from
James Reason, Managing the Risks of Organiza2onal Accidents, 1997
Super Heroes in Med Safety
Joyce
Some poten7al errors:
• Medica7on Selec7on
• Concentra7on
• Route
• Interac7on or Allergy
Wri2ng a single
medica2on order
Annually In Mo@
we administer ~1.2
million drug doses
Resident
Nurse
Med Manager
Pharmacist
If together we are 99.9%
accurate
3-4 errors reach the patient
every day

9. 9
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

10. 10
Compounded Meds

11. 11
Solution
• Standards developed
• Website created – mipedscompounds.org
– Includes standards, recipes, references
•

12. 12
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