The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.

… Jt Comm J Qual Patient Saf … Safety II is a proactive approach to …

Diagnostic errors can result in increased length of stay and unplanned hospital readmissions. To reduce readmissions, this hospital implemented a diagnostic time-out to increase the frequency of documented differential diagnosis in pediatric patients admitted with abdominal pain. Results showed marginal improvement in quality of differential diagnosis.

Diagnostic errors remain an ongoing patient safety challenge and can result in patient harm. This article describes one large pediatric hospital's experience using a systematic methodology to identify and measure diagnostic errors. The quality improvement (QI) project used five domains (autopsy reports, root cause analyses (RCAs), voluntary reporting system, morbidity & mortality conference, and abdominal pain trigger tool) and adjudication by a QI team to identify cases of diagnostic error; Morbidity & mortality conferences, RCAs and abdominal trigger tool identified the majority (91%) of diagnostic errors.   

Over a 2-month period, researchers surveyed pediatric clinicians to asses their comfort discussing medical errors (involving both systems and individual clinician responsibility) during morbidity & mortality conferences and privately with their peers. Respondents were least comfortable publicly discussing errors and were significantly less comfortable discussing diagnostic errors compared with other medical errors. The greatest barriers to discussing errors involved public perception of clinical performance.   

The traditional approach to patient safety, frequently referred to as Safety-I, involved responding to adverse events and near misses after they happened. Safety-II is characterized by a more proactive approach that focuses on ensuring actions go as planned. This qualitative and exploratory study sought to understand whether Safety-II behaviors and system aspects contributed to the low adverse drug event rates observed in a single pediatric intensive care unit.

… Journal of patient safety … J Patient Saf … Appropriate hand hygiene is essential for …

Improving patient safety often involves multifaceted interventions intended to change complex workflows. This prospective cohort study examined whether a collaborative improvement initiative across 33 pediatric hospitals could augment patient safety. Hospitals volunteered to be part of the collaborative and paid an annual fee to participate. All but one submitted their safety data for inclusion in the study. The intervention involved identification and dissemination of evidence-based practices to reduce hospital-acquired conditions and prevent serious adverse events. Each hospital implemented these best practices locally according to their preferences. The collaborative provided virtual and in-person training for patient safety processes, such as unit-based safety rounds, root cause analysis, and inclusion of patients and families on hospital committees. Rates of hospital-acquired conditions and serious adverse events declined over time during the 3-year study. Because there were no concurrent control hospitals, it is not clear whether these improvements can be attributed to the intervention. The authors conclude that participation in a learning collaborative can enhance patient safety.

This review discusses key patient safety concepts such as systems thinking, the role of leadership in a culture of safety, use of failure analysis tools, and the value of teams in establishing efforts and behaviors that result in sustainable improvement.

A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.

Allowing families to activate medical emergency teams (METs) may aid in the early detection of clinical deterioration. However, physicians have expressed concerns that families do not understand when an MET is necessary and that this responsibility could present an undue stress on family members. This study reports on the experience of family-activated MET calls over a 6-year period at an academic children's hospital. There were 83 family-activated MET calls, representing less than 3% of all MET responses at this hospital. Families most frequently requested METs for concerns regarding clinical deterioration, but less than one-quarter of these calls resulted in patients being transferred to an intensive care unit, compared to 60% of clinician-activated METs. Since families called METs only between one to two times per month, the program was not felt to pose a substantial burden. The authors also point out that some family-activated METs identified other clinically relevant information that may not have otherwise been shared with the primary clinical team, as well as important communication issues that could have led to adverse events.

… The Journal of pediatrics … J Pediatr … This time-series analysis demonstrated that a …

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … This commentary describes the …

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Retrospective analysis of adverse events …

A medication event huddle team completed more intervention projects following the implementation of a standardized electronic database for tracking assignments.

… The Journal of pediatrics … J Pediatr … The focus of safety programs is shifting from …

… The Journal of pediatrics … J Pediatr … This commentary describes how a tool developed to …

This case-control study documents the clinical consequences and additional costs associated with catheter–associated bloodstream infections, and uses these data to make the business case for efforts to prevent such infections.

This AHRQ-funded study describes the implementation of an Institute for Healthcare Improvement–style quality improvement collaborative aimed at reducing narcotic-related adverse drug events (ADEs). Fourteen participating hospitals adopted a series of recommended interventions while tracking ADE rates in a pre- and postintervention study design. Investigators discovered a 67% reduction in narcotic-related ADE rates, and also noted decreased rates of constipation and automated drug-dispensing overrides in patients receiving narcotic therapy. The authors point out several limitations to the study, including the inability to measure compliance with the intended change packages at each hospital. This study provides a nice example of the challenges in evaluating multifaceted quality improvement interventions despite its successful outcomes.