Pediatric Mental Health Tops 2023 List of Safety Concerns

March 15, 2023 – The pediatric mental health crisis, made worse by the COVID-19 pandemic, is the top patient safety concern of 2023, according to a new report from a top U.S. patient safety and research firm. 

“Even before COVID-19, the impact of social media, gun violence, and other socioeconomic factors were causing elevated rates of depression and anxiety in children,” Marcus Schabacker, MD, PhD, president and CEO of the research group ECRI, said in a news release. “The challenges caused by the pandemic turned a bad situation into a crisis. We’re approaching a national health emergency.”

According to a study in JAMA Pediatrics, rates of anxiety and depression in children ages 3 to 17 increased by 29% and 27%, respectively, from 2016 to 2020. The average number of weekly visits to emergency departments for adolescents’ suspected suicide attempts was 39% higher in winter 2021 than in winter 2020, the CDC has documented. And a 2021 CDC survey of U.S. high school students found 30% of girls said they’d seriously considered attempting suicide, which was double the rate among boys and up almost 60% from a decade ago. Almost half of LGBTQ students said they’d considered suicide.

ECRI, an independent nonprofit organization dedicated to improving safety, quality, and cost-effectiveness in health care, made several recommendations to address the pediatric mental health crisis. Among other things, ECRI’s experts suggested performing universal child mental health screenings during every office and hospital visit. In addition, they recommended that primary care providers make “warm handoffs” of patients and families to therapists whom they trusted.

In an interview, Schabacker said that it’s not enough for a primary care provider to simply tell a child’s parents to pick a therapist from an insurance list and make an appointment. The clinician should refer the patient to a mental health professional that they are familiar with, whether that be a therapist in private practice or one employed by a school or a church. In addition, he said, the practitioner should make sure that the therapist has the right information about the patient and knows why they were referred. 

Doctors should also be made aware of the extent of the crisis and the long-term effects of mental health conditions that go untreated, Schabacker said. And they should bear in mind that children who are LGBTQ, minority, and/or socially disadvantaged have a far higher risk of a severe mental crisis than heterosexual white children do. 

How Staff Shortages Impact Safety

Since the start of the pandemic, staff shortages in hospitals and doctors’ offices have affected several of the top 10 safety issues, according to ECRI. Staffing shortages, in fact, was the top safety concern in ECRI’s 2022 report. Among other things, these shortages have played a role in the number two safety concern this year: “Physical and verbal violence against health care staff.”

If an emergency room is understaffed, for example, it can take a long time for a patient to be seen, and some patients or their family members might become frustrated and angry. They might then confront an ER nurse. 

“We’ve seen a dramatic increase in violence against nurses,” Schabacker said. When nurses and doctors are overworked because of staff shortages, they might not have the patience to calm people down and de-escalate situations.

Another result of staff shortages is that some health care professionals may be “expected to work in areas outside their scope of practice and competencies” (item number 4 on the list). This can lead to less effective care, Schabacker said.

“Staffing shortages directly influence clinical staff assignments, and gaps need to be filled,” he said. “And when you’re constantly on the run, constantly stressed, constantly at your limit, it’s much more likely that you will miss things.”

Fallout of Dobbs Decision

Another example of how changes in society affect health care is the number three concern on ECRI’s list: “Clinician needs in times of uncertainty surrounding maternal-fetal medicine.” 

This refers to the U.S. Supreme Court’s Dobbs decision, which overturned Roe v. Wade and turned the issue of abortion’s legality back to the states.

Explaining how this change affects patient safety, the ECRI report says, “Uncertainty has now arisen in many states regarding which reproductive services may be provided and when. This uncertainty can lead to refusals of or delays in care that ultimately may not be considered to violate the law. Although some states with abortion bans allow abortions to save the life of or prevent harm to the pregnant patient, there is often little guidance on where the line is. If clinicians wait too long, patients may suffer serious harm.”

Obviously, health care providers can’t change the law, but Schabacker said health care organizations are obligated to tell doctors exactly what the law requires. 

“If a woman experiences serious health events with her pregnancy, and the physician is unclear about what he or she is allowed to do in those situations, because of the uncertainty created by the Supreme Court decision, that causes risk and will lead to safety events and harm to the mothers,” he said.

Health care leaders need to be proactive and provide clear guidance about what is and isn’t allowed. 

Erroneous Medication Lists

ECRI also calls out “medication errors resulting from inaccurate patient medication lists.” The report notes that “inconsistent knowledge and record keeping about medications cause up to 50% of medication errors in hospitals and up to 20% of adverse drug events.” 

While these medication documentation errors occurred in hospitals, Schabacker said, medication lists in ambulatory care may contain even more mistakes. “A study conducted in patient homes prior to a doctor’s visit discovered that medication discrepancies ranged from 14% to 98%,” he said.

The most frequent examples are omitting drugs from the medication list or including discontinued medications.