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Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.  

 A 3-month-old male infant, born at 26 weeks’ gestation with a history of bowel resection and anastomosis due to necrotizing enterocolitis, was readmitted for abdominal distension and constipation. He was transferred to the pediatric intensive care unit (PICU) for management of severe sepsis and an urgent exploratory laparotomy was scheduled for suspected obstruction. The PICU team determined that the patient was stable for brief transport from the PICU to the operating room (OR).

Deacon A, O’Neill T, Delaloye N, et al. Hosp Pediatr. 2020;10(9):758-766.
This qualitative study used a resuscitation simulation to explore the effect of family presence during resuscitation on team performance. Thematic analyses identified five key factors that are influenced by the presence of a parent during resuscitation – resuscitation environment, affective responses, cognitive responses, behavioral responses, and team dynamics.
Thull-Freedman J, Mondoux S, Stang A, et al. CJEM. 2020;22(6):738-741.
This commentary reviews the principles of high reliability organizations and their application to emergency department pandemic response and describes the experience of one children’s hospital in Alberta, Canada applying these principles in responding to the COVID-19 pandemic. Actions taken by the hospital included the use of an interprofessional ED quality council to identify processes where high reliability is essential in the context of the COVID-19 pandemic, such as resuscitations, intubations, donning and doffing of personal protective equipment (PPE), and preventing contamination.

Child Health Patient Safety Organization. Washington DC: Children's Hospital Association; May 2020.

Effective communication is an important component of diagnostic accuracy. Shaped with data collected by a patient safety organization, this five section toolkit features tactics to support effective communication across diagnostic process in children’s hospital care, including the use of time outs, case analysis and communication gap assessment.
Parikh K, Hochberg E, Cheng JJ, et al. Pediatrics. 2020;145(5):e20191819.
This article explores one hospital’s use of facilitated apparent cause analysis  (ACA), which is defined as a limited investigation of a safety event resulting in limited or no harm and allows for fewer resources and a focus on preventative strategies. The article compares ACA versus root cause analysis and describes the process for completing facilitated ACA and the framework for an effective ACA, which includes (1) identifying the right event, (2) assembling the right team, (3) conducting the right analysis, and (4) focusing on the right action plan.
The Institute for Professionalism and Ethical Practice. Fundamentals of Disclosure Coaching. Boston Children's Hospital, Harvard Medical School. March 27, 2020, 1:00-4:00 PM, Boston, MA.
Error disclosure skills are unique and rarely used, yet stressful, emergent situations often necessitate their use. This workshop shares strategies to develop coaches to rapidly aid clinicians involved in error. This strategy helps clinicians get the support they need to effectively apologize and discuss error with the patients, families and teams involved.
Yamada NK, Catchpole K, Salas E. Seminars in perinatology. 2019;43:151174.
Human factors are frequently an important contributing factor to patient safety events. This review describes the role of human factors in patient safety and presents three case studies of human factors affecting care in the NICU. A PSNet Human Factors Primer on human factors expands on these concepts.
Hoonakker PLT, Wooldridge AR, Hose B-Z, et al. Intern Emerg Med. 2019;14(5):797-805.
Patient acuity and the need for interdisciplinary collaboration contribute to patient safety issues in trauma care. This qualitative study explored perceptions of handoff safety in pediatric trauma patients and found a high potential for information loss due to the rapidity of handoffs and the multiple disciplines involved.
Adelman JS, Applebaum JR, Southern WN, et al. JAMA Pediatr. 2019;173(10):979-985.
A classic study found that the replacing the usual naming convention for newborns ("Babygirl" or "Babyboy") with one incorporating the mother's first name (e.g., "Marysgirl" or "Marysboy") reduced wrong-patient errors. Based on this finding, The Joint Commission issued a National Patient Safety Goal (NPSG) requiring the use of distinct naming systems for newborns. The authors of this study noted that the new standard would still leave multiple-birth infants vulnerable to wrong-patient errors, as most hospitals adopted naming standards that left room for confusion between infants (e.g., twin infants might be named "Marysgirl1" and "Marysgirl2"). Researchers examined the rate of wrong-patient errors in six neonatal intensive care units of two health systems that used the NPSG recommended naming conventions, comparing multiple-birth infants to singleton infants. They measured wrong-patient errors by tracking the rate of orders that were retracted and then immediately reordered for a different patient. The rate of wrong-patient errors was significantly higher among multiple-birth infants, most of which could be explained by intrafamilial errors (e.g., a medication was ordered for one twin when intended for another). The accompanying editorial points out that this study is an important example of carefully assessing the real-world impact of novel policies; in this case, the NPSG likely does protect against wrong-patient errors for singleton infants, but not for multiple-birth infants.
Orenstein EW, Ferro DF, Bonafide CP, et al. JAMIA Open. 2019;2(3):392-398.
Handoffs represent a vulnerable time for patients when lapses in communication may adversely impact safety. Prior research has shown that medication errors occur frequently among patients transferred from ICU to non-ICU locations within the same hospital. In this qualitative study, physicians reviewed transfer notes and handoff documents for 50 patients transferred from a pediatric ICU to a medical unit. They found clinically relevant differences between the handoff and transfer note documentation in 42% of the transfers and conclude that such discrepancies are both common and place patient safety at risk. A previous WebM&M commentary described an adverse event related to a patient handoff.
Elger BM, Esparaz JR, Nierstedt RT, et al. Journal of Pediatric Surgery. 2020;55.
Prior research has shown that engaging parents in promoting the surgical safety of pediatric patients is viewed positively by both parents and staff. In this study, researchers assessed the impact of a digital application, SafeStart, on parental engagement in surgical safety. The application was presented to parents via tablet and required parents to verify safety information for their child throughout the surgical process. They found that use of the application improved parents' knowledge of surgical safety and that parents preferred it to standard surgical consent processes.
Cifra CL, Houston M, Otto A, et al. Jt Comm J Qual Patient Saf. 2019;45(8):543-551.
Checklists allow health care teams to adhere to best practices. In a single institution's pediatric intensive care unit, a quality champion who prompted teams to discuss a safety checklist daily facilitated a reduction in urinary catheter days and length of stay. However, the patients cared for during the quality champion's tenure had lower illness severity.
Brunsberg KA, Landrigan CP, Garcia BM, et al. Acad Med. 2019;94(8):1150-1156.
Physician burnout and depression are prevalent, costly, and likely to worsen the existing physician shortage. Physicians with depression and burnout also report committing more errors than their peers. Investigators prospectively examined whether pediatric residents reporting depression or burnout were involved in more errors. Participants experiencing depression committed three times as many harmful errors as those without depression. Residents with burnout did not commit more errors or more harmful errors. A strength of this study is that the errors were assessed objectively rather than by self-report. The direction of causality remains unclear—whether physicians with depression commit more harm or committing harm leads to depression. A past PSNet interview discussed how to promote physician satisfaction and well-being.
Meyer AND, Giardina TD, Khanna A, et al. Int J Health Care Qual. 2019;31(9):g107-g112.
This interview study examined how pediatric clinicians communicate diagnostic uncertainty to parents. Researchers found that the clinicians adjusted their explanations based on patient factors like health literacy and on the strength of the clinician–family relationship. The authors conclude that the variability in communicating diagnostic uncertainty signals a need to develop and test best practices.
Siddiqui A, Ng E, Burrows C, et al. Cureus. 2019;11:e4376.
This randomized simulation study examined the use of checklists during simulated pediatric cardiac arrests in the surgical setting. Despite low uptake of the checklists, their availability during the simulations was associated with better performance. The authors recommend use of these checklists to enhance performance in rare critical situations.
Reynolds TL, DeLucia PR, Esquibel KA, et al. JAMIA Open. 2019;2:49-61.
This pre–post mixed-methods implementation study examined a handheld decision support tool for nurses performing bedside administration of intravenous medications in intensive care units. Investigators found that though nurses desire decision support, the usability of the tool and fit with the critical care environment were suboptimal, leading to limited use. The authors suggest integrating mobile technology tools into existing infrastructure and developing user-informed implementation strategies.
Beekman M, Emani VK, Wolford R, et al. Journal of medical education and curricular development. 2019;6:2382120519842539.
This commentary describes the development, implementation, and assessment of a novel patient safety curriculum for medical students. The program builds on a structured communication reporting model to introduce students to the key patient safety concepts and establish a safe environment to raise awareness of concerns they encountered while providing care.
Boston Children's Hospital; Institute for Professionalism and Ethical Practice; IPEP.
Health care students and professionals require training to effectively participate in difficult conversations. This institute conducts research and develops programs to help clinicians communicate successfully with patients and families during stressful care experiences.