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- Communication Improvement 4
- Culture of Safety 3
- Education and Training 1
- Error Reporting and Analysis 5
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Quality Improvement Strategies 1
- Transparency and Accountability 1
Search results for "Pediatric Surgery"
- Pediatric Cardiology
- Pediatric Surgery
Journal Article > Commentary
Weick KE, Sutcliffe KM. Calif Manage Rev. Winter 2003;45:73-84.
Despite an unacceptably high rate of postoperative mortality, surgeons at the Bristol Royal Infirmary continued to perform pediatric cardiac surgery until the United Kingdom Department of Health intervened. A subsequent inquiry revealed that as many as 35 deaths over a 5-year period could have been prevented, and two surgeons lost their licenses. This analysis explores the deficiencies in safety culture that allowed such poor outcomes to go unaddressed. A prior study also discussed the scandal's implications for hospital quality improvement efforts.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Journal Article > Study
Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.
Bowermaster R, Miller M, Ashcraft T, et al. J Am Coll Surg. 2015;220:149–155.e3.
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.
Journal Article > Study
National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths.
Hickey EJ, Nosikova Y, Pham-Hung E, et al. J Thorac Cardiovasc Surg. 2015;149:496-507.
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.
Cases & Commentaries
- Web M&M
Jim Fackler, MD, and Jamie M. Schwartz, MD; October 2011
Residents and nurses assumed an ICU attending was conveying information to the surgeon and cardiologist about a toddler's deteriorating condition after heart surgery. However, none of the providers had a complete picture of the child's status, and he suffered a cardiac arrest.
Sower VE, Duffy JA, Kohers G. American Society for Quality. August 2008.
This article describes the application of Formula One pit stop techniques to improving hand-off systems within a health care setting in the context of one British hospital's research on teamwork in Formula One pit crews.
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.
London, England: The Stationery Office; July 2001.
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.