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Search results for "Health Care Executives and Administrators"

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Journal Article > Study

Rudeness and medical team performance.

Riskin A, Erez A, Foulk TA, et al. Pediatrics. 2017;139:e20162305.

Disruptive and rude behavior by clinicians can hinder teamwork and diminish patient safety. In this simulation study, neonatal intensive care unit teams were randomized to exposure to rude comments versus neutral comments, with two additional teams randomized to exposure to rudeness with either a cognitive bias mitigation intervention or a narrative intervention. Rudeness was associated with worse performance, but training health care professionals to avoid cognitive distraction ameliorated the negative effect of rudeness.

Journal Article > Study

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-571.

Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.

Journal Article > Study

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

Tawfik DS, Sexton JB, Kan P, et al. J Perinatol. 2017;37:315-320.

Burnout has been linked to work dissatisfaction and increased rates of adverse events. This retrospective study found that burnout was prevalent among health care workers in the neonatal intensive care unit setting. In high-volume centers, burnout was correlated with higher rates of health care–associated infections. These results demonstrate the association between burnout and care quality.

Journal Article > Study

Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative.

Bennett SC, Finer N, Halamek LP, et al. Jt Comm J Qual Patient Saf. 2016;42:369-376.

Checklists and debriefing improve patient safety across multiple care settings. In this quality improvement initiative, participating hospitals reported high levels of adherence and satisfaction to a protocol for neonatal resuscitation that included a checklist, briefings, and debriefings. The authors advocate for these safety processes to be included in neonatal resuscitation guidelines.

Journal Article > Study

Safe implementation of standard concentration infusions in paediatric intensive care.

Arenas-López S, Stanley IM, Tunstell P, et al. J Pharm Pharmacol. 2017;69:529-536.

Pediatric medication safety is particularly challenging due to complexity around weight-based dosing. According to a retrospective study in a pediatric intensive care unit, most morphine-related medication administration errors could have been prevented with technology interventions such as barcode medication administration. The authors advocate for implementing standardized morphine infusions to improve safety.

Journal Article > Study

Perceived factors associated with sustained improvement following participation in a multicenter quality improvement collaborative.

Stone S, Lee HC, Sharek PJ. Jt Comm J Qual Patient Saf. 2016;42:309-319.

This implementation study examined factors that affect sustained improvement associated with an intervention to increase the rate of premature infants receiving breast milk. Investigators found that physician involvement and continuous education contributed to maintaining the intervention. Human factors efforts such as incorporating the intervention into daily workflow and providing feedback also supported this safety practice.

Journal Article > Study

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.

Aydon L, Hauck Y, Zimmer M, Murdoch J. J Clin Nurs. 2016;25:2468-2477.

Efforts to improve medication safety in hospital settings often target nurses, such as utilizing barcode medication administration or limiting interruptions during nurses' medication administration tasks. Nurses can also support medication safety by speaking up about medication orders that appear to be incorrect. In this interview study, neonatal intensive care unit nurses were asked to describe scenarios in which they did and did not question medication administration. Investigators found that nurses spoke up about medication administration because of concern for patients and when they felt confident in their medication knowledge. Nurses' work environment could bolster or hinder questioning of medication administration. Interventions to support a positive safety culture and to enhance nurses' medication knowledge could reinforce safe medication administration.

Journal Article > Review

Medication safety in neonatal care: a review of medication errors among neonates.

Krzyzaniak N, Bajorek B. Ther Adv Drug Saf. 2016;7:102-119.

Medication errors are prevalent in inpatient care. This narrative review compared medication errors in neonatal care with those across hospitalized pediatric, adult, and elderly patients. Common types of errors among hospitalized neonatal patients were patient misidentification and overdosing. The authors provide recommendations to improve medication safety for this vulnerable population, which includes integrating a clinical pharmacist into the direct care team.

Journal Article > Study

Transforming the morbidity and mortality conference to promote safety and quality in a PICU.

Cifra CL, Bembea MM, Fackler JC, Miller MR. Pediatr Crit Care Med. 2016;17:58-66.

Traditional morbidity and mortality conferences were designed to focus on educational opportunities to learn from medical errors. In this study, introducing a structured systems-oriented morbidity and mortality conference in a pediatric intensive care unit led to higher attendance rates and more proposed local quality improvement interventions.

Journal Article > Study

Comparing NICU teamwork and safety climate across two commonly used survey instruments.

Profit J, Lee HC, Sharek PJ, et al. BMJ Qual Saf. 2016;25:954-961.

Health care organizations measure safety climate by surveying providers and staff at all levels. Investigators assessed safety culture and teamwork in 44 neonatal intensive care units using two different survey tools—the Safety Attitudes Questionnaire and the Hospital Survey on Patient Safety Culture. They found significant variation in safety and teamwork climate scales of both tools, indicating that the instruments should not be used interchangeably.

Journal Article > Study

The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.

White WA, Kennedy K, Belgum HS, Payne NR, Kurachek S. Jt Comm J Qual Patient Saf. 2015;41:550-562.

Serious reportable events in hospitals are usually captured, but less serious events and near misses often go undocumented. Such close calls can reveal important safety hazards. This study describes the development and early experience of an active surveillance program in a pediatric intensive care unit (PICU). Under the supervision of an assigned intensive care physician, premedical college graduates served as quality/safety analysts. Two analysts canvassed the PICU each morning, interviewing night nurses, physicians, respiratory therapists, and pharmacists about potential adverse events. Over a 15-month period, 2465 events were recorded, representing 5.4 events per day. Approximately 158 quality and safety improvement projects were initiated during this period. The authors describe the infrastructure, reporting, and unique web application that were developed as a part of this process. These quality/safety analyst interviews essentially created a facilitated, robust voluntary incident reporting system.

Journal Article > Study

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

Hughes KM, Goswami ES, Morris JL. J Pediatr Pharmacol Ther. 2015;20:453-461.

Drug shortages can result in safety consequences, as studies have shown a higher rate of treatment failure and increased adverse events associated with unavailability of first-line therapies. However, this study did not find any change in adverse events in pediatric intensive care unit patients during a shortage of commonly used sedatives and injectable opioid pain medications. The authors note that advance warning of the shortage and development of standardized algorithms for drug substitution may have mitigated the potential safety hazards.

Journal Article > Commentary

Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning.

Williams EA, Nikolai DA, Ladwig L, Miller C, Fredeboelling E. Jt Comm J Qual Patient Saf. 2015;41:508-513.

Rapid teamwork has been highlighted as a mechanism to enhance response to patient deterioration, assess incidents, improve team feedback, and support high reliability. This commentary discusses the development and implementation of the SWARM tool—a unit-based mechanism to rapidly analyze problems and develop solutions—in a pediatric intensive care unit. The authors detail the results of the initiative and provide materials to enable organizations to implement a similar program.

Journal Article > Study

The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety.

Frey B, Doell C, Klauwer D, et al. Pediatr Crit Care Med. 2016;17:67-72.

Interdisciplinary morbidity and mortality conferences were an effective way to identify system failures contributing to medical errors, in this report from a children's hospital in Switzerland. The study analyzed 48 morbidity and mortality conferences over a 5-year period and gives examples of the 34 system improvements that were put into place as a result.

Journal Article > Study

Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures.

Shaw SJ, Jacobs B, Stockwell DC, Futterman C, Spaeder MC. Jt Comm J Qual Patient Saf. 2015;41:414-420.

Adherence to quality and safety measures (such as informed consent, presence of urinary catheters, deep venous thrombosis prophylaxis, and medication reconciliation) improved in a pediatric intensive care unit after implementation of an electronic dashboard which displayed real-time data about each of these practices. This study illustrates the importance of providing real-time data to frontline providers as a method to augment adherence to patient safety practices.

Journal Article > Study

Higher quality of care and patient safety associated with better NICU work environments.

Lake ET, Hallowell SG, Kutney-Lee A, et al. J Nurs Care Qual. 2016;31:24-32.

This survey of nurses found that those who rated their work environment as poor were more likely to report quality and safety problems, underscoring the well-described link between nurses' working conditions and patient safety. Improving nurse working conditions is a patient safety strategy.

Journal Article > Study

Use of temporary names for newborns and associated risks.

  • Classic

Adelman J, Aschner J, Schechter C, et al. Pediatrics. 2015;136:327-333.

Wrong-patient errors are considered to be never events. Newborns are assigned temporary names if they don't have a name immediately after birth, and this may increase the rates of wrong-patient errors. The need for first and last names in electronic health records has led to a generic first name convention of "Babygirl" or "Babyboy," which is in use in more than 80% of neonatal intensive care units in the United States. This pre-post study found that implementing specific first names that incorporated the mother's name reduced the incidence of wrong-patient errors by 36% compared to the generic naming. These errors are rare even at baseline, but given the ease of changing the naming convention, this is a pragmatic approach to improving the safety of computerized provider order entry for hospitalized newborns.

Journal Article > Study

Information gaps in newborn care and their potential for harm.

Kumar P, Biswas A, Iyengar H, Kumar P. Jt Comm J Qual Patient Saf. 2015;41:228-233.

Interviews with mothers were compared with maternal prenatal histories and infant medical records in this study, revealing that a majority of patients had at least one information gap in which pertinent data was not recorded in the medical record. While such incomplete information has been documented previously, these errors of omission raise concern for adverse events and demonstrate the need for new strategies.

Journal Article > Study

Analysis of medication prescribing errors in critically ill children.

Glanzmann C, Frey B, Meier CR, Vonbach P. Eur J Pediatr. 2015;174:1347-1355.

Prescribing errors are a common and serious problem for hospitalized pediatric patients. This prospective observational study in a single pediatric intensive care unit found an overall error rate of 14%. This study also defined several risk factors for prescribing errors in these patients and analyzed the severity of the most frequent errors.

Journal Article > Study

Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital.

Bonafide CP, Lin R, Zander M, et al. J Hosp Med. 2015;10:345-351.

Previous studies have documented high frequency of alarms for nurses in intensive care settings. This direct observation study of a pediatric intensive care unit found that response times increased when there were more preceding nonactionable alarms, demonstrating a delay in alarm response due to alarm fatigue. This finding underscores the importance of improving current alarm management.

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