Reducing central line-associated bloodstream infections (CLABSI) is an important patient safety improvement target. This study examined the relationship between compliance with evidence-based CLABSI guideline bundles and CLABSI rates in 159 hospitals. Between 2011 and 2021, researchers found that adherence to bundle guidelines was associated with a significant reduction in CLABSI rate.

Previous research has found that racial and ethnic disparities can hinder the safe care of pediatric patients. In this cross-sectional study, researchers examined racial and ethnic disparities in central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) rates across 27 children’s hospitals in the United States. Compared to White patients, Black and African-American patients had higher UE rates and Hispanic, Native American, and Pacific Islander patients had higher CLABSI rates.

I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.

… was interviewed in 2016 for a PSNet perspective . … Coffey M, Marino M, Lyren A, et al. Association between …

Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.

… patient safety. … Zaheer S,  Ginsburg L, Wong HJ, Thomson K, Bain L, Wulffhart Z. Acute care nurses' …

Establishing a culture of safety within health care organizations requires strong leadership support. This cross-sectional survey study of nurses, allied health professionals, and unit clerks working in the inpatient setting at a single hospital found that positive perceptions of senior leadership support for safety and positive perceptions of teamwork were associated with positive perceptions of patient safety. In addition, when staff perceived senior leadership support for safety to be lacking, the positive impact of direct managerial leadership on staff perceptions of patient safety was more pronounced.

Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.

Reducing harm often requires implementing multicomponent interventions and engaging frontline staff to make change. Prior research has shown that cross-institutional collaboration can facilitate sharing of data and dissemination of best practices to improve safety. The Children's Hospitals' Solutions for Patient Safety (SPS) Network fosters collaboration across 137 hospitals in the United States and Canada to reduce harm from hospital-acquired conditions and adverse events. Hospitals share their data through SPS and have an opportunity to learn from one another. This study describes the efforts of SPS and concludes that since 2012, an initial group of 33 hospitals has successfully reduced harm across eight conditions by anywhere from 9% to 71%. This represents almost $150 million in savings from harm avoided for an estimated 9000 children. A prior WebM&M commentary discussed a medication error that involved a young infant.

… to disclosure may be improving over time. … Wong BM, Coffey M, Nousiainen MT, et al. Learning Through Experience: …

Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.

Research has established that disclosure of medical errors to patients and families is essential for maintaining a therapeutic alliance. However, less is known about what patients and families may expect regarding the disclosure of near misses. In this interview study, parents of hospitalized children expressed varying preferences surrounding disclosure of errors, near misses, and the degree to which they desired their children participate in the disclosure process.

Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.

The number of handoffs a patient experiences while hospitalized has almost certainly increased at academic institutions after the implementation of duty hour restrictions, posing a significant threat to patient safety. In response, The Joint Commission required that all hospitals maintain a standardized approach to handoff communication, and in 2010 the Accreditation Council for Graduate Medical Education required that all residents receive formal handoff training. This multicenter study demonstrates that implementation of a standardized handoff bundle—which included a mnemonic ("I-PASS") for standardized oral and written signouts, formal training in handoff communication, faculty development, and efforts to ensure sustainability—was associated with a 23% relative reduction in the incidence of preventable adverse events across 9 participating pediatric residency programs. This improvement was achieved through a very high level of resident engagement in the revised handoff process, but did not negatively affect resident workflow. This rigorously designed and analyzed study establishes the I-PASS model as the gold standard for effective clinical handoffs and demonstrates the value of methodologically stringent approaches to addressing patient safety issues. A case of a delayed diagnosis due to poor handoffs is discussed in a past AHRQ WebM&M commentary.

This systematic review attempted to quantify the excess attributable cost of patient safety events in hospital care but found considerable methodologic weaknesses in the available literature addressing this question.

Hospitalized children are particularly vulnerable to specific types of errors, such as medication errors. This Canadian study used a trigger tool approach to estimate the frequency of all types of adverse events in hospitalized children, and found that nearly 1 in 10 pediatric patients suffers an adverse event while hospitalized. This prevalence is similar to classic studies performed in adult populations. Preventable adverse events, which accounted for approximately half of all events, were particularly common in children undergoing surgery or requiring intensive care. Diagnostic errors also accounted for a significant proportion of preventable adverse events. A preventable error in a critically ill 8-month-old child is discussed in an AHRQ WebM&M commentary.

Progress has been achieved in several areas of patient safety, but the cost-effectiveness of successful interventions remains an important question for policymakers and organizational leadership. This systematic review evaluated the cost-effectiveness of interventions to address 15 key safety targets (including health care–associated infections, adverse drug events, retained foreign bodies after surgery, and wrong-site surgery), but identified only 7 methodologically adequate economic analyses. Based on this limited dataset, the authors identified 4 cost-effective safety interventions, including checklists to prevent catheter-related bloodstream infections and medication reconciliation conducted by pharmacists. More robust economic analyses will be required in order to help prioritize safety interventions in the future.

Pediatric residents reported a high degree of awareness and responsibility for disclosing errors to patients, but most would still choose their words carefully when disclosing an error. In focus groups, it became apparent that residents' willingness to fully disclose errors was dependent on social contextual factors (for example, their perceived degree of direct responsibility for the error, or their place in the team hierarchy).

Trigger tools are widely used as a means of detecting adverse events in adult patients. This study reports on a novel trigger tool for detection of preventable errors in hospitalized children.