Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

Heather Wolfe; Jesse Wenger; Robert M. Sutton; Roopa Seshadri; Dana E. Niles; Vinay Nadkarni; Jordan Duval-Arnould; Anita I Sen; Adam Cheng

Study

Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

September 2, 2020

Wolfe H, Wenger J, Sutton RM, et al. Pediatr Qual Saf. 2020;59(4):e319.

View more articles from the same authors.

This article describes the use of “cold” debriefings performed more than one day after in-hospital cardiac arrest events at institutions participating in a pediatric resuscitation quality collaborative. Cold debriefings took place in one-third of events; the median time to debriefing was 26 days. The majority of comments arising from the debriefings involved clinical standards, cooperation and communication.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Safety in pediatric hospice and palliative care: a qualitative study.

September 23, 2020

Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes.

May 25, 2016

Improving patient handoffs and transitions through adaptation and implementation of I-PASS across multiple handoff settings.

September 16, 2020

Making care better in the pediatric intensive care unit.

January 30, 2019

Better nurse staffing is associated with survival for Black patients and diminishes racial disparities in survival after in-hospital cardiac arrests.

December 9, 2020

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit.

January 15, 2020

Design and implementation of an analgesia, sedation, and paralysis order set to enhance compliance of pro re nata medication orders with Joint Commission medication management standards in a pediatric ICU.

December 9, 2020

Delayed time to defibrillation after in-hospital cardiac arrest.

January 16, 2008

Adverse events related to accidental unintentional ingestions from cough and cold medications in children.

August 26, 2020

Call to action: addressing pediatric fall safety in ambulatory environments.

December 1, 2021

Improving accuracy of handoff by implementing an electronic health record-generated tool: an improvement project in an academic neonatal intensive care unit.

October 21, 2020

Structuring feedback and debriefing to achieve mastery learning goals.

May 18, 2016

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

October 20, 2021

Health care-associated infections among critically ill children in the US, 2013-2018.

October 28, 2020

Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion.

December 2, 2020

Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients.

December 14, 2005

Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist.

September 2, 2020

Race, ethnicity, and 60-day outcomes after hospitalization with COVID-19.

November 17, 2021

COVID-19: patient safety and quality improvement skills to deploy during the surge.

June 24, 2020

Quantifying discharge medication reconciliation errors at 2 pediatric hospitals.

October 27, 2021

Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study.

October 21, 2020

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

November 25, 2020

The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors.

February 10, 2021

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

Nurse-reported bullying and documented adverse patient events: an exploratory study in a US Hospital.

June 24, 2020

The calm before the storm: utilizing in situ simulation to evaluate for preparedness of an alternative care hospital during COVID-19 pandemic.

June 2, 2021

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Registered nurses' judgments of the classification and risk level of patient care errors.

October 19, 2011

"Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation.

December 9, 2020

Implicit racial bias in pediatric orthopaedic surgery.

June 15, 2022

Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia.

August 10, 2022

In situ simulation: an essential tool for safe preparedness for the COVID-19 pandemic.

November 25, 2020

Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery.

February 3, 2021

Hospital medication errors: a cross sectional study.

December 23, 2020

Economic evaluation of quality improvement interventions to prevent catheter-associated urinary tract infections in the hospital setting: a systematic review.

March 30, 2022

Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre.

July 22, 2020

Key potentially inappropriate drugs in pediatrics: the KIDs list.

June 24, 2020

Physician task load and the risk of burnout among US physicians in a national survey.

December 2, 2020

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

September 30, 2020

Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.

June 22, 2022

Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture.

September 2, 2020

Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure.

March 9, 2022

Pediatric transport safety collaborative: adverse events with parental presence during pediatric critical care transport.

November 10, 2021

Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite longitudinal assessment.

February 15, 2023

Time series evaluation of improvement interventions to reduce alarm notifications in a paediatric hospital.

February 12, 2020

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center.

August 12, 2020

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

August 25, 2010

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

December 9, 2020

Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program.

November 23, 2005

Perceptions of nurses who are second victims in a hospital setting.

December 22, 2021

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Characteristics of critical incident reporting systems in primary care: an international survey.

January 19, 2022

A model for improving health care quality for transgender and gender nonconforming patients.

January 23, 2020

Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing.

January 18, 2023

March 11, 2020

Omissions of care in nursing homes: a uniform definition for research and quality improvement.

November 18, 2020

Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study.

October 7, 2020

US emergency department visits for acute harms from over-the-counter cough and cold medications, 2017-2019.

December 15, 2021

To what extent is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations? A descriptive study.

February 16, 2022

Am I safe? An interpretative phenomenological analysis of vulnerability as experienced by patients with complications following surgery.

January 18, 2023

A quality improvement initiative to improve patient safety event reporting by residents.

February 9, 2022

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.

May 12, 2021

Association between hospital acquired harm outcomes and membership in a national patient safety collaborative.

August 10, 2022

Chronic hospital nurse understaffing meets COVID-19: an observational study.

September 9, 2020

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

September 2, 2020

Characteristics and unexpected COVID-19 diagnoses in resuscitation room patients during the COVID-19 outbreak - a retrospective case series.

September 30, 2020

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

August 25, 2021

Errors during resuscitation: the impact of perceived authority on delivery of care.

March 25, 2020

Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.

July 15, 2020

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Hospital cultural competency and attributes of patient safety culture: a study of U.S. hospitals.

November 17, 2021

A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital.

April 27, 2022

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

The impact of the built environment on patient falls in hospital rooms: an integrative review.

June 16, 2021

Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals.

May 26, 2021

Repurposing clinical decision support system data to measure dosing errors and clinician-level quality of care.

November 11, 2020

Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients.

March 2, 2022

Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being.

June 8, 2022

Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review.

March 25, 2020

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event.

April 5, 2023

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

May 11, 2022

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.

July 29, 2020

Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative study.

November 17, 2021

Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.

November 3, 2010

Using the opportunity estimator tool to improve engagement in a quality and safety intervention.

January 18, 2012

A qualitative exploration of the impact of a distressed family member on pediatric resuscitation teams.

October 7, 2020

Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats.

June 8, 2022

Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative.

October 5, 2022

Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes.

November 12, 2014

An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review.

December 8, 2021

Managing teamwork in the face of pandemic: evidence-based tips.

June 24, 2020

Factors influencing family member perspectives on safety in the intensive care unit: a systematic review.

December 9, 2020

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

August 10, 2011

Critical care simulation education program during the COVID-19 pandemic.

November 10, 2021

Unintended consequences of health care reform: impact of changes in payor mix on patient safety indicators,

October 7, 2020

Pediatric surgical errors: a systematic scoping review.

July 20, 2022

The impact of a 22-month multistep implementation program on speaking-up behavior in an academic anesthesia department.

July 27, 2022

Related Resources

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

STAMP: a 5-year project to reduce paediatric prescribing errors.

April 19, 2023

Race and socioeconomic bias in pediatric cardiac transplantation.

February 8, 2023

Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content.

November 16, 2022

Resident and nurse perspectives on the use of secure text messaging systems.

October 19, 2022

Neuroradiology diagnostic errors at a tertiary academic centre: effect of participation in tumour boards and physician experience.

August 17, 2022

Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.

July 6, 2022

Parent participation in morbidity and mortality review: parent and physician perspectives.

June 22, 2022

Journal Article

Study

Patient Safety Innovations

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

April 7, 2022

March 16, 2022

The Top Six: standardized safety practices in U.S. Army Medical Department treatment facilities worldwide.

February 23, 2022

Improving hospital infant safe sleep compliance by using safety prevention bundle methodology.

February 2, 2022

Associations between safety outcomes and communication practices among pediatric nurses in the United States.

January 19, 2022

Optimizing situation awareness to reduce emergency transfers in hospitalized children.

October 20, 2021

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children.

June 30, 2021

Safety events in children's hospitals during the COVID-19 pandemic.

May 26, 2021

Awareness of human factors in the operating theatres during the COVID-19 pandemic.

January 13, 2021

WebM&M Cases

Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability

December 23, 2020

Increasing physician reporting of diagnostic learning opportunities.

December 23, 2020

Pediatric trainees' speaking up about unprofessional behavior and traditional patient safety threats.

September 30, 2020

Effect on patient safety of a resident physician schedule without 24-hour shifts.

July 15, 2020

Improving timely recognition and treatment of sepsis in the pediatric ICU.

May 27, 2020

Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool.

March 18, 2020

Time series evaluation of improvement interventions to reduce alarm notifications in a paediatric hospital.

February 12, 2020

Encouraging resident adverse event reporting: a qualitative study of suggestions from the front lines.

October 30, 2019

Adverse events in long-term care residents transitioning from hospital back to nursing home.

August 7, 2019

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.

July 10, 2019

Perception of patient safety culture in pediatric long-term care settings.

February 13, 2019

Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists.

January 9, 2019

Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children.

December 19, 2018

See More About The Topic

Hospitals

Quality and Safety Professionals

Pediatrics

Pediatric Cardiology

Medical Complications

Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site