(1287) Defining and Implementing a Taxonomy to Assess Medication Safety in a Pediatric Intensive Care Unit

Introduction: Medication-related adverse events (MRAEs) are an important cause of morbidity and mortality in the pediatric intensive care unit (PICU) environment. We aimed to characterize the incidence of MRAEs and their primary failure modes during a vulnerable period of significant PICU expansion. Our secondary aim was to identify trends and targets for interventions to improve safety.

Methods: In a 30-bed pediatric intensive care unit at an academic quaternary medical center, we implemented a taxonomy consisting of, 1) Healthcare Performance Improvement (HPI) Safety Event Classification (SEC) and the Serious Safety Event Rate (SSER) Patient Safety Measurement System for Healthcare, 2) four main steps in medication delivery workflow, and 3) level of patient harm. A team of multidisciplinary raters applied this taxonomy to all MRAEs, collected by the pediatric intensive care unit , from January 2021 to December 2022.

Results: A total of 323 MRAEs were collected from January 2021 to December 2022. MRAEs were classified as primarily “prescribing” (22%), “dispensing” (40%), “reconciliation” (23%) or “administration” (15%) events. Using the HPI SEC and SSER schema, they were also classified as “system” (54%) or “individual” (46%) failure modes. System failures modes were primarily related to “process” (52%) or “technology/environment” (28%). Individual failures modes primarily included deficits in “consciousness” (61%) or “competency” (16%). The majority of these events were “near misses” (41%) or “no harm” (43%).

Conclusions: MRAEs continued to be a significant contributor of overall adverse events in the PICU. The events happen across the entire spectrum of medication delivery workflow, and are related to both individual and systems factors. MRAEs classified as near misses reflected opportunities to identify individual and system-level vulnerabilities with a potential for harm. Identification of these trends in vulnerabilities will help target and prioritize interventions such as education, competency assessment, process improvement, and environmental modifications, to mitigate MRAE risks in the complex PICU environment.