Suboptimal care in the initial management of children who died from severe bacterial infection: a population-based confidential inquiry.

OBJECTIVES: To study the frequency and types of suboptimal care and medical errors in children who died of severe bacterial infection as the first-stage procedure intended to improve quality of care. DESIGN: Population-based confidential inquiry. SETTING: Two adjoining administrative districts in France. PATIENTS: Children older than 3 months dead from severe bacterial infection from 2000 through 2006. INTERVENTIONS: The medical files were summarized on standardized forms and then evaluated independently by two experts, who determined whether the initial management before the patients' arrival in intensive care was or was not optimal, in comparison with current guidelines. MEASUREMENTS AND MAIN RESULTS: Of 23 deaths from severe bacterial infection, 21 could be analyzed; management was considered suboptimal in 76%. The coefficient of agreement between the experts was high, with a weighted kappa of 0.73. The types of errors identified included parental delay in seeking medical care (33%; 95% confidence interval, [12-54]), physicians' delay in administering appropriate treatment (antibiotic therapy in the case of purpura; 38%; 95% confidence interval, 16-60), insufficient doses of or failure to repeat fluid resuscitation (24%; 95% confidence interval, [9 -35]), and overall underestimation of disease severity (38%; 95% confidence interval, [16-60]). CONCLUSION: This study found a high frequency of suboptimal care in the initial management of children who died of severe bacterial infection, with four separate types of errors. Other studies are needed to assess the potential avoidability of this type of death.