Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.

Reducing diagnostic errors in pediatric care remains a critical area of research and quality improvement. This narrative review presents the incidence and epidemiology of pediatric diagnostic error and strategies for additional innovative research to develop effective interventions to reduce these errors.

Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 

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Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.

Diagnostic errors in pediatric primary care are common and represent an ongoing patient safety challenge. In this stepped-wedge, cluster-randomized trial, researchers were able to successfully recruit a diverse group of pediatric primary care practices to participate in virtual quality improvement collaboratives designed to reduce diagnostic error.

Pediatric patients are at particularly high risk for medication errors. This retrospective review of voluntary error reports of pediatric antibiotic errors found that less than 15% reached the patient and 1.5% caused harm. The risk varied by medication class, and authors suggest developing quality improvement initiatives focused on the highest risk medications.

In the Improving Diagnosis in Health Care report, the National Academy of Medicine proclaimed that diagnostic errors are common, cause substantial morbidity, and are understudied. This report has led to multidisciplinary efforts to measure diagnostic error rates in both ambulatory and inpatient settings. This study examined the prevalence of three diagnostic errors in pediatric primary care practices. They found that diagnostic errors were common. Providers did not follow up abnormal laboratory values for 11% of patients and did not address adolescent depression in 62% of visits. These high rates are similar to those found in other practice settings. The authors discuss an ongoing quality improvement collaborative working to reduce diagnostic errors in pediatric primary care practices. Previous WebM&M commentaries highlight cognitive and system-level interventions to prevent diagnostic errors.

This commentary describes the development of a multidisciplinary council to collectively lead patient safety efforts for children's hospitals in a large health system. The authors highlight the value the council brought to project coordination, standard setting, and performance improvement across the organization.

Interruptions are known to contribute to medication errors. This direct observation study found that resident physicians and physician assistants experienced 57 interruptions per 100 medication orders. The authors suggest that inpatient health systems should implement strategies to reduce interruptions during medication ordering.

Checklists are widely utilized in health care to promote patient safety. Management of trauma patients is complex, and checklists may facilitate adherence to known standards of care. This pre–post study looked at the impact of the World Health Organization Trauma Care Checklist program across 11 hospitals in 9 countries. Researchers found that adherence to 18 out of 19 care process measures improved after the checklist program was implemented. Although investigators discerned no difference in mortality for the overall study population, they found a 50% reduction in mortality for patients with more severe trauma injuries after implementation of the program. A prior PSNet perspective discussed components of an effective checklist.

Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.

The frequency of diagnostic errors in outpatient care remains unclear. In this survey of outpatient general pediatricians, about one-third reported making a diagnostic error every month. This finding underscores the importance of enhancing the safety of diagnosis in ambulatory settings.

Strategies to educate residents and fellows in quality and patient safety concepts can ensure commitment to improvement work. This commentary describes the development and results of a multispecialty program to expand an existing academic medical center curriculum on quality improvement.

… interventions. … Cifra CL, Bembea MM, Fackler JC, Miller MR. Transforming the Morbidity and Mortality …

This study updates the previously described progress of patient safety efforts at Johns Hopkins Hospital. In 2012, hospital leaders declared their goal of exceeding The Joint Commission Top Performer award thresholds by achieving at least 96% compliance on accountability measures. The program included creating a robust quality management infrastructure through the Armstrong Institute, engaging frontline clinicians in peer learning communities, and transparently reporting monthly data with a detailed step-based accountability plan for underachieving metrics. This study describes how the hospital was able to sustain performance on all of the accountability measures through 2014. The authors attribute their continued success to establishing an enduring quality management infrastructure, a project management office, and a formal accountability framework. This model highlights the degree of organization required to create lasting changes that improve patient safety across health systems.

Some states require public reporting of rates of central line–associated bloodstream infections (CLABSI). Investigators did not find differences in CLABSI rates between states with and without public reporting, suggesting that current transparency efforts are not sufficient to improve this safety target.

This study describes the early experience of a new infrastructure for quality and safety at Johns Hopkins Medicine. A major component of this effort was the 2011 creation of the Armstrong Institute for Patient Safety and Quality. The institute is led by safety expert Dr. Peter Pronovost and currently has approximately 70 staff members, 140 core faculty, and an annual budget of about $15 million. The new governance structure includes oversight from a patient safety and quality board committee. The overall goal of these efforts was to achieve quality metrics that would meet the requirements for the Delmarva Foundation Excellence awards and The Joint Commission's Top Performer award at each of the 5 Johns Hopkins hospitals (2 academic and 3 community institutions). By 2013, the health system reached at least 96% compliance on 6 of 7 targeted measures, with 4 hospitals receiving the Delmarva Foundation award and 2 hospitals garnering the Joint Commission award, making a strong case for the effectiveness of this robust high-reliability strategy.

Similar to prior research in internal medicine and surgical programs, this survey study found that structure and processes of morbidity and mortality (M&M) conferences in pediatric intensive care units varied widely. Moreover, there was substantial disagreement between respondents, making it unclear whether the M&M conferences actually conform to key elements of medical incident analysis.

In this study, applying standardized chart reviews for incidents discussed during morbidity and mortality conferences in a pediatric intensive care unit uncovered many previously unrecognized safety events. Conversely, the conferences revealed near misses and diagnostic errors that were not obvious in chart documentation.