Analysis
The number of PDRC reviews vary from year to year. Chart 1 illustrates the number of PDRC reviews from 2013 to 2022.
Chart 1: Total number of PDRC reviews from 2013—2022
Chart 1: The chart provides the number of reviews completed by the Committee. In 2013 there were 12 reviews, nine in 2014, 11 in 2015, nine in 2016, five in 2017, four in 2018, 12 in 2019, 10 in 2020, 12 in 2021 and six in 2022.
Overview of cases reviewed by the PDRC in 2022
In 2022, the PDRC reviewed a total of six cases involving the deaths of six children (one male child and five female children).
From the cases reviewed in 2022, 50% (3) of the involved children less than a year old, 33% (2) aged one to five years of age and 17% (1) was older than five years of age.
A summary of cases reviewed, and recommendations made in 2022 is included in the Appendix.
Recommendations
One of the goals of the PDRC review is informing medical systems through recommendations using a “no blame” approach. The focus is on preventing further deaths via recommendations for:
- Systemic changes;
- Changes in professional practice; and
- Response to emerging trends.
In 2022, five of the six reviews resulted in a total of nine recommendations. One review resulted in no recommendations.
Summary of recommendations made by PDRC
The recommendations made from the PDRC reviews in 2022 focused on the following themes and were directed to the identified organizations:
| Organization(s) asked to respond to recommendation | Theme of recommendation(s) | Number of reviews where theme was identified 2022 |
|---|---|---|
Healthcare Organization Treating Healthcare practitioners | Quality of Care | 3 |
| Healthcare Organization | Policy and Procedure | 4 |
| Healthcare Organization | Transport | 1 |
| Healthcare Organization | Education/ Training | 1 |
| OCC Regional Office | Other | 1 |
Themes arising during medical reviews
Themes are often identified in individual death reviews and at times patterns may emerge when similar issues are observed in other reviews. Over time, the PDRC has identified and compiled themes that have been observed over time in child and youth death reviews. The benefit of having a thematic approach is that the recurring themes may become an agent for systemic change. Over the past several years, several initiatives stemming from PDRC recommendations have enhanced paediatric health care in Ontario.
Themes in 2022
The cases reviewed by the PDRC in 2022 were associated with five 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 death review. The consistent themes, and issues associated with each, are:
Quality of care
- Airway management including consideration of Anesthesia consultation for airway management in unstable patients.
- Staffing and preparation for acute airway management in premature and/or sick infants.
- Joint quality-of-care reviews between treating healthcare organizations.
Policy and procedures
- Transport timing and decision-making including use of regional/provincial agencies (for example, CritiCall).
- Review of approaches to paediatric airway management.
- Review of Paediatric Advanced Life Support (PALS) standards and practices.
- Review of systems to support appropriate PALS drug dosing.
- Decision process for continuing to use an endotracheal tube without evidence of endotracheal positioning.
- Decision process for the initial attempts at endotracheal intubation.
Transport
- Transport timing protocols and procedures of critically ill children and youth.
Education and training
- Education on recognition and treatment of pneumothorax.
Other
- Referring for a high-risk perinatology consultation.