A prospective observational study of medication errors in a pediatric emergency department.

We present a prospective, observational study evaluating the incidence of medication errors (ME) in a university hospital pediatric emergency department and describe their characteristics and determinants. A systematic analysis of the handwritten prescriptions was conducted by a clinician and pharmacist. Of 11,573 consecutively studied prescriptions in children under 15 years of age, the ME incidence was 0.9% (n=102). The incidence of errors found was statistically significantly higher in children older than 5 years (OR=2.05; P=0.026). There was no significant difference regarding the time of admission (P=0.544), the day of the week (P=0.940), or the affluence of people in attendance at the emergency department. The errors observed were all prescription errors. Most errors were related to analgesic (51%) and antibiotic (30%) treatments. No serious errors were reported. CONCLUSION: We found a low incidence of medication errors in this study. The validation of prescriptions by a senior multidisciplinary staff could contribute to limited medication errors. Measures should be continued to further reduce the incidence of drug errors by calling the attention of prescribers to the most common situations at risk of ME.

[Suboptimal care and severe bacterial infection in the French Caribbean area]. / Soins sub-optimaux et infections bactériennes sévères communautaires aux Antilles françaises.

OBJECTIVE: To study the frequency and types of suboptimal care in initial management of children suffering from a severe bacterial infection (SBI), in a French region where little is known about pediatric SBI epidemiology. METHOD: Retrospective single-center study over a 6-year period. Children between 3 months and 15 years of age, deceased or surviving and admitted to the pediatric intensive care unit of the university-affiliated hospital of Martinique for a community-onset SBI were included in this study. The optimality of the medical care before admission to the pediatric intensive care unit was assessed in a blinded fashion by two independent experts. RESULTS: Twenty-nine of the 30 children suffering from SBI could be analyzed. The median age was 3.7 years (IQR: 1.7-10.4); the mortality rate was 14 % (95 % CI: 1-27 %). Most frequently infections were pulmonary infections (48 %; 95 % CI: 29-67 %), followed by septic shock (44 %; 95 % CI: 25-63 %). Microbiological cultures were positive in 55 % (95 % CI, 36-74 %) (n=16) of the cases, with five pneumococcus and four Streptococcus pyogenes. Of the 29 children included in the study, 72 % (95 % CI: 55-89 %) (n=21) had received at least one episode of suboptimal care. Suboptimal care comprised delay in diagnosis (identification of serious symptoms) in 65 % (95 % CI: 47-83 %), a delay in seeking care in 41 % (95 % CI: 22-60 %), and a delay in the initiation of antibiotics or hemodynamic support in 45 % (95 % CI: 26-64 %) and 38 % (95 % CI: 20-56 %) of the cases, respectively. CONCLUSION: Suboptimal care was frequent in the initial management of SBI, particularly because of a delay in seeking care and the failure of physicians to recognize early signs of SBI. A large public information campaign, focusing on healthcare accessibility and better education of physicians in the early recognition of SBIs are means of improvement that need to be explored.

Variability in the diagnostic performance of a bedside rapid diagnostic influenza test over four epidemic seasons in a pediatric emergency department.

We wanted to determine the diagnostic performance of a rapid influenza diagnostic test (RIDT) used bedside in a pediatric emergency department (PED). This was a prospective study over four consecutive winters (2009-2013), comparing the results of a RIDT (QuickVue®) with RT-PCR in children admitted to a PED. Among the 764 children included, we did not observe any significant differences in the diagnostic performance of RIDT except during the H1N1 pandemic. The overall sensitivity of the test was 0.82; the specificity 0.98; the positive and negative likelihood ratios 37.8 and 0.19. The positive and negative post-test probabilities of infection were 98% and 17%. The diagnostic performance was increased for influenza B cases (P = 0.03). RIDTs are suitable for use every winter with few differences in its diagnostic value, except during specific pandemic periods. This test could limit unnecessary complementary exams and guide the prescription of antivirals during influenza epidemic periods in PEDs.

[New recommendations for the management of children after minor head trauma]. / Actualisation des recommandations pour la prise en charge du traumatisme crânien léger chez l'enfant.

Minor head trauma is a common cause for pediatric emergency department visits. In 2009, the Pediatric Emergency Care Applied Research Network (PECARN) published a clinical prediction rule for identifying children at very low risk of clinically important traumatic brain injuries (ciTBI) and for reducing CT use because of malignancy induced by ionizing radiation. The prediction rule for ciTBI was derived and validated on 42,412 children in a prospective cohort study. The Société Française de Médecine d'Urgence (French Emergency Medicine Society) and the Groupe Francophone de Réanimation et Urgences Pédiatriques (French-Language Pediatric Emergency Care Group) recommend this algorithm for the management of children after minor head trauma. Based on clinical variables (history, symptoms, and physical examination findings), the algorithm assists in medical decision-making: CT scan, hospitalization for observation or discharge, according to three levels of ciTBI risk (high, intermediate, or low risk). The prediction rule sensitivity for children younger than 2 years is 100 % [86.3-100] and for those aged 2 years and older it is 96.8 % [89-99.6]. Our aim is to present these new recommendations for the management of children after minor head trauma.

["Traffic lights" in pediatrics: what do residents beginning their family residency know about them?]. / Les « feux tricolores ¼ en pédiatrie : état des lieux des connaissances en début de 3e cycle de médecine générale.

OBJECTIVES: Pediatric practice is a difficult task requiring physicians to discriminate potentially serious situations among a variety of benign situations. The goal of this study was to assess the knowledge of students beginning their residency in family medicine on these situations. METHODS: One hundred and three students were evaluated on pediatric "traffic lights" using 103 true/false questions. Pediatric and family medicine teachers of the Nantes University Hospital defined "traffic lights" as the fundamentals of pediatrics, misleading situations, and diagnosis and treatment that should not to be missed. Emergency levels were defined by colors, with "red light" corresponding to life-threatening emergencies. RESULTS: Thirty-six percent of the questions (n=103) had a correct response rate below 75%. Thirty-two percent of the questions on emergency situations ("red lights") (n=37) had a response rate below 75%. Fifteen percent of the questions (n=103) had a correct response rate below 50%, half of which were "red light" (e.g., on meningitis, diabetic acidocytosis, or shock). Questions concerning infants (n=24) had significantly fewer correct answers (correct response rate below 50%: 29% versus 10%; P=0.047). All the students answered seven questions correctly. The students' mean score (percentage of good answers) was 76% (±6%). No student had 100% or less than 50% good answers. CONCLUSIONS: Some life-threatening situations or situations concerning infants had not been mastered by most of the students. It is therefore essential to optimize the teaching of pediatrics during the second cycle of medical studies.

[Update on the management of acute viral bronchiolitis: proposed guidelines of Grand Ouest University Hospitals]. / Prise en charge de la bronchiolite aiguë du nourrisson de moins de 1 an : actualisation et consensus médical au sein des hôpitaux universitaires du Grand Ouest (HUGO).

BACKGROUND AND OBJECTIVES: While our European and North American colleagues have recently updated their recommendations, the 2000 Consensus Conference remains the main guideline on management of acute viral bronchiolitis in France. We aimed to establish an updated inter-regional protocol on management of acute viral bronchiolitis in infants. METHOD: Pediatricians, pediatric pulmonologists, and emergency physicians of the Grand Ouest University Hospitals (France) gathered to analyze the recent data from the literature. RESULTS: Criteria to distinguish childhood asthma from acute viral bronchiolitis were established, then prescriptions of diagnostic tests, antibiotics, and chest physiotherapy were defined and reserved for very limited situations. Similarly, the modalities of oxygen therapy prescription and nutritional support were proposed. Finally, other therapeutics such as nebulized hypertonic saline seem promising, but their place in the treatment of acute bronchiolitis in infants remains unclear. CONCLUSION: This work has provided new proposals for management of acute viral bronchiolitis and helped standardize practices within the Grand Ouest University Hospitals. This local organization could lay the keystone for working toward guidelines initiated by learned societies at the national level.

[Management of bronchiolitis in general practice and determinants of treatment being discordant with guidelines of the HAS]. / État des lieux des pratiques médicales en médecine générale en matière de bronchiolite et déterminants de prises en charge thérapeutiques discordantes par rapport aux recommandations de l'HAS.

INTRODUCTION: The Haute autorité de santé released clinical practice guidelines in 2000 to assist in the management of bronchiolitis. These guidelines emphasized supportive care with nasal suctioning and encouraged chest physiotherapy. The aim of this study was to examine the adherence to the french guidelines for the management of bronchiolitis by general practitioners. PATIENTS AND METHODS: The study included infants less than 24 months of age with bronchiolitis, consulting a general practitioner in Vendée or in Loire-Atlantique, from November 2011 to April 2012 and whose parents accepted to participate to the study. The primary endpoint was the concordance of therapeutic practice with the french guidelines (administrated treatments, refer to pediatric emergencies). Data were collected through questionaires completed by general practitioners. RESULTS: Of the 1236 questionnaires distributed, 134 were completed and 118 therapeutic practice were analyzed. A total of 52.5% of therapeutic practice were concordant with guidelines and 57.5% in case of first bronchiolitis. 50% of infants with a hospitalization criteria according to the guidelines, have not been, which probably shows the interest of new guidelines, with highlighting of hospitalization criteria.