Previous research has identified gaps in medication reconciliation practices among hospitalized children. This quality improvement found that increased utilization of a patient-friendly discharge medication platform integrated into the electronic health record (EHR) system was associated with improved inpatient discharge medication reconciliation in pediatric acute care patients.

Research has shown clinicians frequently have implicit biases against patients of color, women, and transgender patients. This study used Implicit Association Tests (IAT) to evaluate implicit bias in pediatric heart transplant clinicians. Results showed these clinicians had a bias, or preference for, individuals who were White, from a higher socio-economic group, and had more education. These results are similar to other adult and pediatric clinicians.

Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.

Anticoagulants are common medications that carry the potential for serious harm if administered incorrectly. This retrospective review of 8,576 patients with atrial fibrillation who received direct oral anticoagulants identified inappropriate dosing in nearly 15% of cases, with most patients receiving an inappropriately low dose. Over one year of follow-up, the authors did not identify any significant difference in the incidence of stroke, embolism, bleeding, or ischemic attacks between patients who were inappropriately, versus appropriately, dosed.

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. 

Continuous vital sign monitoring can generate a large volume of alarm notifications that may not represent meaningful change in clinical status and can lead to alarm fatigue, which has become a patient safety priority. This article describes Plan-Do-Study-Act processes employed in the acute care cardiology unit of a large, urban academic medical center that resulted in a reduction in alarm notifications of 68% over 2.5 years. Patient safety was maintained as these improvements were made and reductions in alarm notifications were sustained for more than 18 months.

In this retrospective study, researchers found that the diagnosis of systolic heart failure had been missed on first presentation for almost 50% of pediatric patients hospitalized with new-onset heart failure. Incorrect diagnostic labels frequently assigned to these patients included bacterial infection, viral illness, and gastroenteritis.

Researchers surveyed pediatric cardiac intensive care unit providers across three tertiary cardiac centers in the United States. More than 80% of respondents perceived diagnostic errors to be common and 65% reported errors causing permanent harm to patients. Improving feedback and teamwork were frequently suggested as strategies for reducing diagnostic error.

Adverse events in prehospital care are an increasing area of focus in patient safety. In this retrospective study, researchers examined the medical records of 35 out-of-hospital cardiac arrests among children younger than 18 transported by a single emergency medical services system. They identified a safety issue in 87% of cases and, similar to prior research, they found that medication errors were common.

Efforts to understand the nature of human error can enhance care safety. Discussing the potential for unexpected human behaviors during crises to result in failure, this commentary reveals how insights drawn from video analysis of teams in critical situations informed adjustments to training to reduce risks in cardiac care.

In this study, the National Aeronautics and Space Administration's error detection model was used to analyze the incidence and types of error in pediatric cardiac surgery procedures. The investigators found that errors occurred in nearly half of all operations and frequently manifested as cycles of error whereby the effect of a single error was compounded by failure to rescue.

This observational study describes how a pediatric cardiac surgery team used the human factors approach of recording even small deviations from ideal practice in order to better characterize safety problems. The authors describe how systematically capturing small failures led to recognition of faulty processes that could be addressed. A recent AHRQ WebM&M commentary discusses the application of human factors engineering to enhance safety of medical device design.

Simulations of prehospital pediatric cardiopulmonary arrest uncovered many potential errors. Most notably, medication errors related to the correct weight-based dosing of epinephrine were common. This mistake can have serious consequences and warrants further efforts to mitigate this risk.

Controversy exists regarding whether children should be required to undergo an electrocardiogram before participating in competitive sports. This study found a significant rate of diagnostic error among pediatric cardiologists in the interpretation of abnormal screening electrocardiograms.