One of the important benefits of PDRC – Medical review is informing medical systems through recommendations using a “no blame” approach. The focus is on preventing further deaths via:

Systemic changes;

Changes in professional practice; and

Response to emerging trends.

Given the PDRC – Medical referral criteria, recommendations are commonly directed to health care facilities. The collective expertise of the committee provides comprehensive reports that can be helpful to inform a healthcare organization’s Quality of Care Review processes. The findings and recommendations in the reports create an opportunity for the organization to see the potential for improvement in its internal processes or policies to avoid similar outcomes in the future.

In 2016, the nine reviews resulted in 18 recommendations. There was one case that resulted in no recommendations.

In 2017, the five reviews resulted in 12 recommendations. There was one case that resulted in no recommendations.

Summary of 2016-2017 recommendations made by PDRC – Medical

The recommendations made from the PDRC – Medical reviews in 2016-2017 focused on the following themes and were addressed to the identified organizations:

Summary of recommendations
Organization(s) asked to respond to recommendation Theme of recommendation(s) Number of reviews where theme was identified 2016 Number of reviews where theme was identified 2017
Health care organizations Treating Health Care Professionals Quality of Care 7 4
Health care organizations Treating Health Care Professionals Differential diagnosis 1 1
Health care organizations Communication 0 2
Health care organizations Documentation 2 1
Health care organizations Transport 1 1

Some cases resulted in multiple recommendations touching on different themes.

Themes arising during medical reviews

Themes are often identified in individual case reviews and sometimes patterns may emerge when similar issues are observed in other reviews. Over time, the PDRC – Medical has identified and compiled a number of themes that have been common in child death reviews. The benefit of having a thematic approach is that the recurring themes can become an agent for systemic change. Over the past several years, there have been a number of initiatives stemming from PDRC – Medical recommendations that have enhanced paediatric health care in Ontario. 

Themes from 2016 and 2017 case reviews

The cases reviewed by the PDRC – Medical in 2016 and 2017 were associated with four key themes. Some cases had more than one theme identified.

While these themes are consistent with past findings, by taking the extra step of evaluating for emerging trends, a refined focus for recommendations is taken with a view of systemic improvement instead of only considering the individual cases. The consistent themes, and issues associated with each, are:

Treatment - quality of care

The following treatment and/or quality of care issues were identified:

  • Emergency room protocols and procedures;
  • Recognition, assessment and management of seriously ill high risk children;
  • Airway management in a child who had serious respiratory illness;
  • Assessment and care of a child during the Paediatric Intensive Care Unit admission;
  • Importance of cultural awareness to ensure effective and culturally informed intersections of health care providers with families;
  • Development of protocols that clarify and separate clinical care discussions such as withdrawal of life support from discussion about consent for organ and tissue donation;
  • Clarity around staff supervision in surgery, neonatology and radiology;
  • Inotropic support and fluid administration in the care of infants in cardiogenic shock;
  • Protocols and guidelines for staff physicians responsible for monitoring and overseeing medical students;
  • Policies for ensuring follow-up of recommendations made for children, particularly those at high risk (including responding to missed follow-up appointments);
  • Discharge planning when it involves at-risk children being discharged to remote/isolated communities.

Differential Diagnosis

Issues with differential diagnosis were identified:

  • Approach to ascertainment of severity of illness to inform decision making;
  • Assessment and management of infants and neonates, particularly when febrile;
  • Detection of congenital heart disease by fetal ultrasound examination;
  • Management of Gastrostomy tube in premature babies;
  • Approach to prioritization for surgical admission when a child is admitted to hospital with maximal medical management.

Documentation

Documentation issues included:

  • Importance of regular collection and charting of a complete set of vital signs;
  • Policies and procedures for logging/documentation of patient/family telephone calls;
  • Review of policies and procedures relating to documentation and retention of patient records;
  • Sharing policies and procedures between the healthcare institutions and child and family services involved.

Transport/Transfer

Transport/transfer issues included:

  • Development of a plan to facilitate transfer if a local transport team is unavailable;
  • Challenges associated with transport of seriously ill paediatric patients;
  • Paediatric and neonatal transport in remote communities;
  • Decision making approach in developing a patient transfer plan.