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Morse KE, Chadwick WA, Paul W, et al. Pediatr Qual Saf. 2021;6(4):e436.
The goal of medication reconciliation is to identify medication inconsistencies at hospital discharge. This study identified six common medication reconciliation errors at discharge – duplication, missing route, missing dose, missing frequency, unlisted medication, and “see instructions” errors. The authors evaluated the prevalence of these errors at two pediatric hospitals and found that duplication and “see instructions” errors were most common. 
Koeck JA, Young NJ, Kontny U, et al. Front Pediatr. 2021;9:633064.
Medication safety in children is a patient safety priority. This systematic review explored interventions to reduce medication dispensing, administration, and monitoring errors in pediatric healthcare settings. The majority of identified studies used “administrative controls” to prevent errors, but those implementing higher-level interventions (such as smart pumps and mandatory barcode scanning) were more likely to result in error reduction.

The handshake antimicrobial stewardship program (HS-ASP) was developed and implemented at Children’s Hospital Colorado (CHCO). In 2014, the CHOC HS-ASP team began labeling specific interventions as “Great Catches” which were considered to have altered, or had the potential to alter, the patient’s trajectory of care. CHOC researchers used these "Great Catches" to identify potential diagnostic errors.

Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148(3):e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Searns JB, Williams MC, MacBrayne CE, et al. Diagnosis (Berl). 2021;8(3):347-352.
This study leveraged “Great Catches” as part of an existing handshake antimicrobial stewardship program (HS-ASP) to identify potential diagnostic errors. Using a validated tool, researchers found that 12% of “Great Catch” cases involved diagnostic error. These cases included a diagnostic recommendation from the HS-ASP team (e.g., recommendations to consider alternative diagnoses, request additional testing, or additional interpretation of laboratory results). As these diagnostic recommendations often flagged diagnostic errors, this suggests that the HS-ASP model can be leveraged to identify and intervene on diagnostic errors in real time.
Levy FH, Conrad KA, Kemper C, et al. Pediatr Qual Saf. 2021;6(4):e449.
Patient safety organizations (PSOs) collect and analyze protected safety incident data from across the United States. This article describes the development of the Child Health PSO and how it evolved into a learning network through alignment around a common goal, collaboration, and information sharing with high levels of engagement from participating children’s hospitals.
Sullivant SA, Brookstein D, Camerer M, et al. Jt Comm J Qual Patient Saf. 2021;47(8):496-502.
Improving screening for suicidal ideation is an important patient safety priority. This article describes the implementation and evaluation of a hospital-wide program to identify teenagers at elevated risk for suicide and to connect them with services. During the first year of implementation, over 138,000 screenings were completed and 6.8% of screens were positive for elevated risk.
Bartman T, Merandi J, Maa T, et al. Jt Comm J Qual Patient Saf. 2021;47(8):526-532.
Safety II is a proactive approach to improving patient safety by learning from what goes right in healthcare. A US children’s hospital developed three tools for frontline clinicians to recognize, mitigate, and learn from potential safety issues at the bedside.
Morrison AK, Gibson C, Higgins C, et al. Pediatr Qual Saf. 2021;6(4):e425.
Limited health literacy can lead to patients or caregivers misunderstanding care instructions. Researchers examined safety events occurring at one children’s hospital over a nine-month period and found that health literacy-related events accounted for 4% of all safety events. Health literacy-related events generally involved problems with medication (e.g., unclear discharge medication instructions, conflicting instructions), system processes (e.g.., failures to address language barriers), and discharge and transitions (e.g., unclear equipment information, unclear instructions about upcoming tests).
Evans S, Green A, Roberson A, et al. J Pediatr Nurs. 2021;61:151-156.
A lack of situational awareness can lead to delayed recognition of patient deterioration. This children’s hospital developed and implemented a situational awareness framework designed to decrease emergency transfers to the intensive care unit (ICU). The framework included both objective and subjective criteria. By identifying patients at increased risk of clinical deterioration (“watcher status”) and use of the framework, recognition of deterioration occurred sooner and resulted in fewer emergency transfers to the ICU.
Geva A, Albert BD, Hamilton S, et al. Pediatr Crit Care Med. 2021;Epub May 4.
Checklists are used in many clinical settings to improve patient safety. This pediatric intensive care unit updated a static checklist, eSIMPLE, to a dynamic, decision-support enhanced checklist, eSIMPLER. The eSIMPLER checklist took less time to complete, had higher user satisfaction, and improved adherence to best-practices.

Parry C. The Pharmaceutical JournalApril 22 2021.

Weight-based prescribing in children harbors challenges to accurate medication dosing. This story discusses an examination of factors contributing to ten-fold medication errors in pediatric care. The author summarizes an ongoing investigation which has identified polypharmacy and information system weaknesses as being among the contributors to the problem.
Uong A, Philips K, Hametz P, et al. Pediatrics. 2021;Epub Mar 13.
Breakdowns in communication between clinicians and patients and their caregivers are common and can lead to adverse events. This article describes the development of the SAFER Care framework for written and verbal discharge counseling in pediatric units. The SAFER mnemonic reminds clinicians delivering discharge counseling to discuss safe return to school/daycare, activity restrictions, follow-up plans expected symptoms after discharge, when to return and seek care for symptoms, and who to contact with questions. Results from caregiver surveys indicate that the SAFER Care framework improved their comprehension of discharge instructions.
Boyle FM, Horey D, Siassakos D, et al. BJOG. 2020;128(4):696-703.
Patients, parents and caregivers play an important role in improving patient safety. Although parents have expressed interest in engaging in perinatal mortality review processes, this international survey of healthcare providers found that less than one-third of respondents (from various types of healthcare facilities) included parents in the review process at their institutions. The authors discuss the potential importance of parental involvement after perinatal mortality to improve care.
Perry MF, Melvin JE, Kasick RT, et al. J Pediatr. 2021;232:257-263.
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.   
Khan A, Yin HS, Brach C, et al. JAMA Pediatr. 2020;Epub Oct 20.
Language barriers between patients and providers is a potential contributor to adverse events. Based on a cohort of 1,666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspeciality patients 17 years and younger, this study examined the association between parents with limited comfort with English (LCE) and adverse events in hospitalized children. Compared with children of parents who expressed comfort or proficiency with English, children of parents who expressed LCE had significantly higher odds of experiencing an adverse event, including preventable events. Future research should focus on strategies to improve communication and safety for this vulnerable group of children.
Hsu HE, Mathew R, Wang R, et al. JAMA Pediatr. 2020;Epub Oct 6.
Catheter-associated urinary tract infections (CAUTI) and central catheter-associated blood stream infections (CLABSI), are common complications in hospitalized patients, particularly among critically-ill children. Using surveillance data from January 2013 to June 2018, the authors did not identify any significant changes in CLABSI rates in NICUs or PICUs.  These trends indicate that past gains in CLABSI rates have held, without evidence of further improvement.  The authors noted modest improvements in CAUTI rates, observing a significant decrease in CAUTI rates in the PICU, corresponding with a significant decrease in indwelling urinary catheter use.
Naseralallah LM, Hussain TA, Jaam M, et al. Int J Clin Pharm. 2020;42(4):979-994.
Pediatric patients are particularly vulnerable to medication errors. In this systematic review, the authors evaluated the evidence on the effectiveness of clinical pharmacist interventions on medication error rates in hospitalized pediatric patients. Results of a meta-analysis found that pharmacist involvement was associated with a significant reduction in the overall rate of medication errors in this population.
Cowden JD, Flores G, Chow T, et al. J Racial Ethn Health Disparities. 2020;7(5):928-936.
Language and cultural barriers can diminish patient safety. This survey of pediatric hospitals across the United States and Canada explored the use of patient/family race, ethnicity, and language preference data. While most hospitals routinely collected language preferences and patient race/ethnicity, parent or guardian race/ethnicity was collected less often. Few hospitals stratified quality and safety measures by race/ethnicity or language preference, which may hinder efforts to identify and eliminate disparities in care.
Foster CB, Ackerman K, Hupertz V, et al. Pediatrics. 2020;146(4):e20192057.
This article describes the implementation and results of catheter-associated urinary tract infection (CAUTI) prevention efforts by a large network of children’s hospitals between 2011 and 2017. Prevention efforts included catheter insertion and maintenance bundles. After implementation of the bundles, CAUTI rates across the network decreased by 61.6%.