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Editorial

Journal of Adolescent Health 38 (2006) 1–4

Are our teenagers safe . . . from us?

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When most of us think of teenagers and safety, we worrybout early or unprotected sex, exposure to violence in theome or community, or injuries both intentional and unin-entional. Rarely do we think about the risks adolescentsace when they receive health care. In this issue of theournal of Adolescent Health, Woods and her colleaguesnd that adolescents may actually be at increased risk ofrror and harm from medical care [1]. Applying the adversevent rate found by Woods et al to the total adolescentospitalizations in this country yields an estimate of over 2illion adverse events annually for children aged 10 to 17

ears [2]. To understand the importance of this study, it isseful to reflect on where we are as a field in addressingatient safety.

Six years after the release of the landmark Institute ofedicine (IOM) report, To Err is Human, there is a sense

hat progress has been slow in improving the safety of caren this country [3–5]. Certainly, we have not reduced theeath rate from error by 50% as called for by the IOM.owever, experts maintain that the stage is now set for us toake substantial improvements in care [4,6]. The health

are quality debate has changed into one in which ournderstanding of the processes and systems needed to pro-ide safe care has increased, interest among payers andurchasers has grown, regulators are requiring hospitals tomplement proven safe practices, research on patient safetyas grown dramatically, and the public is increasingly con-erned about the quality and safety of care [4,7–9]. Aredolescents benefiting from this progress? The answers tohis question is perhaps more disquieting.

Woods and her colleagues have identified several impor-ant aspects of error among adolescents. First and foremost,he study reminds us of the importance of attending to thenique characteristics of health and health care for childrennd youth, characteristics that are often labeled the “fours” [10,11]. Within an error context, understanding adoles-

ents’ developmental trajectory and changing dependencyn their parents and families focuses our attention on theifferential approaches to communication, often a rootause of error. In addition, Woods and colleagues find thathe rates of adverse events and preventable adverse events

n adolescents may more closely approximate those of r

054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. Alloi:10.1016/j.jadohealth.2005.11.024

dults. When examining hospital care, adolescents’ differ-ntial epidemiology is dominated by pregnancy-related andehavioral health admissions, areas that have been less wellxamined by patient safety researchers. Error rates amongregnancy-related hospitalizations were examined, butehavioral-related diagnoses, which represent a substantialroportion of the hospitalizations in the second decade ofife, were not included in their analyses [1,10]. Given thatnly 2.6% of adolescents between the ages of 15 and 17ears are hospitalized each year, there is a need to includembulatory settings in our evaluations of patient safety inhe adolescent population. Finally, adolescent demograph-cs—notably their racial/ethnic diversity, their reliance onublic systems of care and financing systems, and their usef nontraditional settings—require special attention to errormong subgroups of adolescents who may be particularly atisk based upon context [12]. Indeed, adolescent-specificactors were found to contribute to errors in over half54.8%) of the described patient safety problems in Woodst al. [1].

here we are today

Much has changed in the patient safety landscape sincehe collection of the quantitative data in the Woods study.irst, there has been a substantial increase in investment inatient safety research and related activities at the Agencyor Healthcare Research and Quality (AHRQ). From this,e are beginning to understand the drivers of patient safety

hat are relevant to addressing this issue in adolescents. Forxample, we are learning that not all patients experiencerror at the same rate. Flores and others have demonstratedhe increased vulnerability of children from non-English-peaking or limited-English-speaking proficiency familieso clinically significant errors in both outpatient and inpa-ient settings [13–15]. Similarly, researchers are demon-trating that the race and socioeconomic status of patientsay be associated with a greater risk of error. Studies in

dults are increasingly showing that African Americans aret greater risk of poor care, which may be explained in party the organizations and types of providers from whom they

eceive care [16]. Other studies are beginning to link the

rights reserved.

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2 L. Simpson / Journal of Adolescent Health 38 (2006) 1–4

nancing of care to the rate of patient safety events [17,18].nother critical dimension of quality and patient safetypon which research is beginning to shed some light is theelationship between provider organization characteristicsnd error events. Much attention has been paid to the rolehat adequate nurse staffing plays in promoting patientafety [19,20]. Numerous studies have documented the rolehat a higher volume of specific procedures and servicesontributes to improved outcomes [21]. Although there ap-ear to be no studies specifically looking at any of thesessues in adolescent patient safety, Woods et al point outumerous reasons to posit that these factors may be con-ributing to the increased rates of adverse events found inhe study. Adolescents make up a very small portion of evenhe pediatric volume in most hospitals. The majority ofospital personnel are not specifically trained in the care ofdolescents, and fewer than 100 hospitals have designateddolescent units [22]. Finally, it is interesting to note that inhe Woods study, diagnostic errors were among the mostommon preventable adverse events. Diagnostic errors haveeen associated with a proportionately higher morbidityhan is the case with other types of medical errors, and lackf regular exposure to adolescent patients is likely to in-rease diagnostic errors [23].

Given this impressive growth in the patient safety re-earch portfolio, one can pose the perennial question: Havehildren and adolescents been included in the portfolio at anppropriate level? Athough this is difficult to answer em-irically, a few indicators point to minimal attention todolescents. In searching the nearly 1500 resources in-luded in the AHRQ-sponsored online patient safety net-ork resource center, only 57 of 421 reports classified by

linical area were pediatric, and 27 of the 543 hospitalector reports were in children’s hospitals [24]. Similarly, ofhe over 100 cases posted to AHRQ’s Web M & M (“Mor-idity & Mortality Rounds on the Web”), only 11 cases areediatric and only three appear to focus on adolescents [25].

Turning from the changes in the research landscape,uch has also changed for American hospitals since these

ata were collected. First, the Joint Commission on Accred-tation of Healthcare Organizations (JCAHO) moved aheaduickly in the last six years to develop and now enforce aroad set of standards focusing on patient safety [4,26].nother change since 1992 is how error reporting systems

nd requirements have evolved. At the time of the IOMeport, 15 states had mandatory reporting systems [27]. Thisas now grown to 22 states, with mandatory reporting sys-ems covering 63% of the U.S. population [26].

Finally, a number of efforts in the private sector havemerged to improve patient safety overall, and patient safetyor children and youth specifically. After the Institute forealthcare Improvement launched their bold “100,000 Livesampaign” in December 2004, child health organizations wereuick to join forces and soon launched a pediatric-specific

ocus led by the National Initiative for Children’s Healthcare c

uality in collaboration with the Child Health Corporation ofmerica and the National Association of Children’s Hospitals

nd Related Institutions [28].

oving forward

If patient safety experts are right, the next five years wille a time of significant progress in addressing patient safety.ow can we assure that adolescents are included in thisrogress? Four steps may help keep our focus on improvinghe health of adolescents.

urther understanding of the scope and unique dimen-ions of error in adolescence. Woods et al provide us withhe first step, but much work remains to elucidate the rootauses and adolescent-specific factors that contribute torror in this population in all clinical settings. There willeed to be an expansion of investments from AHRQ andther federal agencies such as the Food and Drug Admin-stration, the Centers for Disease Control and Prevention,nd foundations. Health service researchers will need to payncreased attention to the adolescent population—the ado-escent medicine research community needs to expand itsortfolio to include this critically important area and en-ourage a new generation of investigators to tackle this areaithin fellowship training programs.

evelopment of tools and measures. We are still at the earlytages of development of well-tested and validated mea-ures of patient safety that are appropriate for children anddolescents. Although some of the safe practices recom-ended by the National Quality Forum (NQF) are applica-

le to children and adolescents, most of the consensuseasurement development activities of the NQF have not

een child-—let alone adolescent—-sensitive. This is be-inning to change, as the NQF held its first child-specificorkshop in January 2004 and began the development ofediatric measures sets related to asthma and medicationanagement [29]. In addition, the AHRQ indicators used byiller et al are being re-examined as part of the develop-ent of an expanded and improved pediatric quality indi-

ators set.

he role of health information technology (HIT). We haveitnessed an explosion of interest in HIT in the last twoears as leaders in the public and private sectors haveoped that investments in electronic health records andecision support tools such as computerized physicianrder entry will significantly reduce medical error [30].ortunately, the leadership of pediatric organizations, asell as many pediatric informaticians, is heavily en-aged, and a focus on children is appearing in many HITettings. What has not yet become apparent is what if anyttention to adolescent-specific issues will occur in the

oming years.

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3L. Simpson / Journal of Adolescent Health 38 (2006) 1–4

he importance of leadership. For safety to improve, lead-rship is needed at multiple levels. First and foremost, theommunity of adolescent specialists should acknowledgehat patient safety is an important issue worthy of researchnd policy attention. Of the 22 policy statements availablen the Society for Adolescent Medicine’s (SAM) website,one is focused specifically on patient safety [31]. Indeed,espite the ever-growing evidence base of the problems ofoor quality care for adolescents in this country, there areone on the overall quality of care issues for adolescents—uality is addressed as a small paragraph in the 2004 posi-ion paper on adolescent access to health care [32]. It isnteresting to note that SAM does have a position paperating back to 1996 calling for adolescent inpatient units,ut as this predates the current safety movement, it is not atll framed in a quality/safety framework [22]. Second, weeed leadership on the part of those providing care todolescents. The field of quality improvement is mountingfforts to go beyond myriad small and often disjointedmprovement projects to focus on organizational transfor-ation. Within pediatrics, we certainly have our own ex-

mples of outstanding leadership, which is leading to suchransformation. Cincinnati Children’s Hospital has em-raced transparency, benchmarking, and the inclusion ofamilies to improve cystic fibrosis care [33]. Transforma-ional efforts such as these require focused and sustainedeadership.

hat can be done?

Too many children and adolescents are experiencingarm from the very systems that should be protecting andupporting them. As a community of scholars and stake-olders in children and adolescents, we have a responsibilityo take the results by Woods and her colleagues seriouslynd ask ourselves what can be done. Adolescents need ourelp in so many ways. We need to add patient safety to thatist.

cknowledgment

Supported in part by the Pediatric Clinical Researchenter of All Children’s Hospital and the University ofouth Florida, and the Maternal and Child Health Bureau,60 MC 00003-01, Department of Health and Human Ser-ices, Health Resources and Services Administration.

Lisa Simpson, MB, BCh, MPH, FAAPDepartment of Pediatrics

University of South Florida

St. Petersburg, Florida

eferences

[1] Woods DM, Holl JL, Klein JD, Thomas EJ. Patient safety prob-lems in adolescent medical care. J Adolesc Health 2006;38:5–12.

[2] Simpson L, Owens PL, Zodet MW, et al. Health care for children andyouth in the United States: annual report on patterns of coverage,utilization, quality, and expenditures by income. Ambul Pediatr 2005;5:6–44.

[3] Kohn LT, Corrigan JM, Donaldson M, eds. Institute of Medicine(IOM) Report—To Err is Human: Building a Safer Health System.Washington, DC: National Academy of Sciences; 1999.

[4] Leape LL, Berwick DM. Five years after To Err is Human: what havewe learned? JAMA 2005;293:2384–90.

[5] Brennan, TA, Gawande A, Thomas E, Studdert D. Accidentaldeaths, saved lives, and improved quality. N Engl J Med 2005;353:1405–9.

[6] Altman, DE, Clancy C, Blendon RJ. Improving patient safety—fiveyears after the IOM report. N Engl J Med 2004;351:2041–3.

[7] Safe Practices for Better Health Care: A Consensus Report. Wash-ington, DC: National Quality Forum; 2003.

[8] Kaiser Family Foundation, Agency for Healthcare Research andQuality, Harvard School of Public Health. National Survey on Con-sumers’ Experiences with Patient Safety and Quality Information.Menlo Park, CA: Kaiser Family Foundation; 2004.

[9] Schoen C, Osborn R, Huynh PT, et al. Taking the pulse of health caresystems: experiences of patients with health problems in six coun-tries. Health Aff (Millwood) 2005;W5:509–25.

10] Forrest C, Simpson L, Clancy C. Child health services research:challenges and opportunities. JAMA 1997;277:1787–93.

11] Irwin CE Jr, Burg SJ, Uhler Cart C. America’s adolescents: wherehave we been, where are we going? J Adolesc Health 2002;31:91–121.

12] Newacheck PW, Hung YY, Park MJ, et al. Disparities in adolescenthealth and health care: does socioeconomic status matter? HealthServ Res 2003;38:1235–52.

13] Flores G. The impact of medical interpreter services on the qualityof health care: a systematic review. Med Care Res Rev 2005;62:255–99.

14] Cohen AL, Rivara F, Marcuse EK, et al. Are language barriersassociated with serious medical events in hospitalized pediatric pa-tients? Pediatrics 2005;116:575–9.

15] Flores G, Laws M, Mayo SJ, et al. Errors in medical interpretationand their potential clinical consequences in pediatric encounters.Pediatrics 2003;11:6–14.

16] Bach PB, Pham HH, Schrag D, et al. Primary care physicians whotreat blacks and whites. N Engl J Med 2004;351:575–84.

17] Miller M, Zhan C. Pediatric patient safety in hospitals: a nationalpicture in 2000. Pediatrics 2004;113:1741–6.

18] Encinosa WE, Bernard DM. Hospital finances and patient safetyoutcomes. Inquiry 2005;42:60–72.

19] Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospitalnurse staffing and patient mortality, nurse burnout, and job dissatis-faction. JAMA 2002;288:1987–93.

20] Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. Theworking hours of hospital staff nurses and patient safety. Health Aff(Millwood) 2004;23:202–12.

21] Russell K, Hartling L, Tjosvold L, Crumley E, Klassen TP. Volume-outcome relationship in pediatric health care services: a systematicreview. BMC Pediatr (Submitted).

22] Fisher M, Kaufman M. Adolescent inpatient units: a position state-ment of the Society of Adolescent Medicine. J Adolesc Health 1996;18:307–8.

23] Graber M, Gordon R, Franklin N. Reducing diagnostic errors in

medicine: what’s the goal? Acad Med 2002;77(10):981–92.

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24] Author’s calculation from the AHRQ Patient Safety Network [cited2005 Nov 20]. Available from: http://psnet.ahrq.gov.

25] Author’s calculation from the AHRQ Web M&M: Morbidity andMortality Rounds on the Web [cited 2005 Nov 2]. Available from:http://www.webmm.ahrq.gov/caseArchive.aspx?view�specialty.

26] Bleich S. Medical Errors: Five Years after the IOM Report. NewYork, NY: The Commonwealth Fund; 2005.

27] Rosenthal J, Riley T, Booth M. Medical errors and adverse events: areport of a 50-state survey. Portland, ME: National Academy for StateHealth Policy; 2000.

28] National Initiative for Children’s Healthcare Quality. [cited 2005 Nov

7]. Available from: http://www.nichq.org/NICHQ/.

29] National Quality Forum. Child Health Quality Measurement andReporting. Washington, DC: National Quality Forum; 2004.

30] Johnson KB, Davison CL. Information technology: its importance tochild safety. Ambul Pediatr 2004;4(1):43–6.

31] Society for Adolescent Medicine. [cited 2005 Nov 4]. Availablefrom: http://www.adolescenthealth.org/PositionPapers.htm.

32] Morreale MC, Kapphahn CJ, Elster AB, et al. Access to health carefor adolescents and young adults. Position paper of the Society forAdolescent Medicine. J Adolesc Health 2004;35:342– 4.

33] Gawande A. The bell curve: what happens when patients find outhow good their doctors really are? The New Yorker 2004:80(38):

81–92.