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Search results for "United States of America"

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Journal Article > Commentary

Tools and methods for quality improvement and patient safety in perinatal care.

Nathan AT, Kaplan HC. Semin Perinatol. 2017;41:142-150.

Quality improvement methods are crucial to implement lasting change. This commentary reviews frameworks and tools such as fishbone diagrams, checklists, and process maps that organizations can utilize to improve safety in perinatal care.

Journal Article > Study

A family-centered rounds checklist, family engagement, and patient safety: a randomized trial.

Cox ED, Jacobsohn GC, Rajamanickam VP, et al. Pediatrics. 2017;139:e20161688.

Family-centered rounding is a key patient engagement strategy for hospitalized children. In this cluster-randomized trial that included nearly 300 families, 2 pediatric inpatient services implemented a checklist to promote family-centered rounding and 2 services provided usual care. Through observation of video-recordings, investigators determined that teams who were given a checklist were more likely to ask families if they had questions and to read back provider orders for confirmation. Although families' perceptions of safety climate improved with checklist implementation, overall quality and safety ratings between the checklist and usual care groups were similar. This trial provides evidence that performing certain elements of the checklist, such as read back, can modestly enhance patient and family engagement.

Journal Article > Commentary

An innovative collaborative model of care for undiagnosed complex medical conditions.

Nageswaran S, Donoghue N, Mitchell A, Givner LB. Pediatrics. 2017;139:e20163373.

Lack of collaboration among the clinical team can contribute to diagnostic problems. This commentary describes a collaborative model of care developed to enhance interdisciplinary teamwork across health care settings as a strategy to augment diagnosis for children with undiagnosed complex medical conditions.

Journal Article > Study

Evaluating serial strategies for preventing wrong-patient orders in the NICU.

Adelman JS, Aschner JL, Schechter CB, et al. Pediatrics. 2017;139:e20162863.

Wrong-patient errors are a well-established risk in the health care setting. Research has shown that providers, often multitasking, may enter notes or medication orders for the wrong patient. A prior study touted point-of-care photographs as a helpful intervention for identifying and preventing wrong-patient errors in a cardiothoracic intensive care unit. However, less is known about wrong-patient errors in the neonatal intensive care unit (NICU) population and ways to prevent them. Researchers analyzed more than 850,000 NICU orders and more than 3.5 million non-NICU orders in pediatric patients over a 7-year period. At baseline, they found that wrong-patient orders occurred more frequently in the NICU population with an odds ratio of 1.56. Interventions included requiring reentry of patient identifiers prior to order entry as well as a new naming system for newborns. Implementation of both led to a 61.1% reduction in wrong-patient errors in the NICU population from baseline. A previous WebM&M commentary highlights a case of wrong-patient identification.

Journal Article > Study

Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.

Bonafide CP, Localio AR, Holmes JH, et al. JAMA Pediatr. 2017 Apr 10; [Epub ahead of print].

Bedside monitors alert nurses to clinical deterioration. This prospective observational study examined nurse responses to bedside physiologic monitors. The mean response time was over 10 minutes. Less than 1% of alarms were actionable, underscoring the importance of addressing alarm fatigue.

Journal Article > Commentary

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.

Rosen M, Mueller BU, Milstone AM, et al. Jt Comm J Qual Patient Saf. 2017;43:224-231.

This commentary describes the development of a multidisciplinary council to collectively lead patient safety efforts for children's hospitals in a large health system. The authors highlight the value the council brought to project coordination, standard setting, and performance improvement across the organization.

Journal Article > Study

Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention.

Walsh KE, Bacic J, Phillips BD, Adams WG. J Patient Saf. 2017 Mar 22; [Epub ahead of print].

This study sought to improve safe at-home pediatric medication administration through an interactive voice response intervention. Researchers found that medication dosing errors and nonadherence were common. The intervention increased medication communication but did not make parents more likely to bring medications to a physician visit as recommended. This study highlights the challenges of safe medication management for outpatients.

Journal Article > Study

Barriers and facilitators of adverse event reporting by adolescent patients and their families.

Sawhney PN, Davis LS, Daraiseh NM, Belle L, Walsh KE. J Patient Saf. 2017 Mar 7; [Epub ahead of print].

Prior studies have demonstrated that patients and families can report adverse events that would not otherwise have been detected. This qualitative study explored perceptions of adolescent patients and their parents about adverse event reporting. Positive perceptions of care led to participants being more willing to report an adverse event; whereas, if they felt the quality of care was poor, they would be less likely to report. In addition, families who perceived providers as good communicators were more comfortable with reporting adverse events. Families were interested in multiple modes of reporting including face-to-face meetings, internet-based reporting, live telephone calls, paper mail, and smartphone-enabled reporting of adverse events.

Journal Article > Study

Pediatric prehospital medication dosing errors: a national survey of paramedics.

Hoyle JD Jr, Crowe RP, Bentley MA, Beltran G, Fales W. Prehosp Emerg Care. 2017;21:185-191.

This survey of paramedics found that pediatric dosing errors in the prehospital period are common. Respondents used varied methods for estimating weight of pediatric patients in order to calculate drug doses, and they advocated for pediatric training and standardized weight estimation methods to reduce risks. These findings suggest several possible interventions to enhance pediatric medication safety in the prehospital setting.

Journal Article > Study

Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study.

Guise JM, Hansen M, O'Brien K, et al. BMJ Open. 2017;7:e014057.

Prehospital emergencies are time critical, and they occur in uncontrolled and often challenging environments. Although emergency medical services (EMS) providers are known to experience high levels of stress, whether their stress contributes to patient safety problems is unclear. In this qualitative study, investigators analyzed perceptions of stress and safety in pediatric out-of-hospital emergencies. They identified factors that contribute to increased stress and therefore adversely affect patient safety, including provider sympathy for children and identification with children or family, which participants felt could cloud their clinical judgment, and lack of familiarity with pediatric emergencies, as seen in other clinical settings. This study highlights a need for specific pediatric training for EMS providers to enhance safety.

Journal Article > Study

Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care.

DeCourcey DD, Silverman M, Chang E, et al. Pediatr Crit Care Med. 2017;18:370-377.

Medication reconciliation is critical to safe medication use. This prospective cohort study identified high rates of unintentional medication discrepancies among hospitalized children and young adults. The authors conclude that current medication reconciliation practices are inadequate to ensure medication safety.

Journal Article > Review

Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors.

Dreisinger N, Zapolsky N. Pediatr Emerg Care. 2017;33:128-131.

Emergency departments (ED) are complex environments that are prone to medical error. This review discusses elements of ED care that detract from patient safety and highlights the importance of reporting and discussing errors when they take place to develop prevention strategies. The authors also explore the evidence on transparency in the ED when an error occurs and how to make an appropriate apology.

Journal Article > Study

Radiologic safety events within a pediatric emergency medicine network.

Blumberg SM, Mahajan PV, O'Connell KJ, et al. Pediatr Emerg Care. 2017;33:92-96.

This study analyzed a database of voluntarily reported errors to determine the types of radiologic errors encountered in a regional pediatric emergency medicine network. Radiologic errors accounted for 7% of all incident reports, of which the most common were incorrect or changed interpretations of studies. Individual errors—including clinical judgment or failure to follow established safety procedures—were judged to be more common than system factors, though only half of the incident reports described contributing causes.

Journal Article > Study

Improving communication with primary care physicians at the time of hospital discharge.

Destino LA, Dixit A, Pantaleoni JL, et al. Jt Comm J Qual Patient Saf. 2017;43:80-88.

Adverse events after hospital discharge are common. Prior research demonstrates that communication and information transfer between inpatient providers and primary care physicians (PCPs) may be lacking, raising patient safety concerns. This study described how applying Lean methodology, enhancing frontline provider engagement, and redesigning workflow processes within the electronic health record led to improved communication with PCPs around the time of hospital discharge. Through these interventions, the pediatric medical service was able to increase verbal communication with PCPs at discharge to 80%, and they sustained this for a 7-month period. Discharge communication with PCPs across other services improved as well. A previous PSNet perspective discussed the challenges associated with care transitions and suggested opportunities for improvement.

Journal Article > Study

Finding diagnostic errors in children admitted to the PICU.

Davalos MC, Samuels K, Meyer AND, et al. Pediatr Crit Care Med. 2017;18:265-271.

Despite increased focus on improving diagnosis as a major patient safety issue, measuring and defining diagnostic error remains challenging. A prior study showed that application of the Safer Dx Instrument—a structured tool to help identify diagnostic errors in the primary care setting—enabled improved detection of diagnostic errors compared to chart review alone. In this study, researchers tested the ability of the instrument to identify diagnostic errors in high-risk patients admitted to the pediatric intensive care unit. Out of 214 high-risk patient charts, 26 were found to contain a diagnostic error. Two clinicians independently reviewed the records using the tool and reviewer agreement was 93.6%, suggesting that the Safer Dx Instrument may be useful in additional clinical settings. An Annual Perspective discussed the challenges associated with diagnostic error.

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 > Commentary

The development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists.

Clebone A, Burian BK, Watkins SC, Gálvez JA, Lockman JL, Heitmiller ES; Members of the Society for Pediatric Anesthesia Quality and Safety Committee. Anesth Analg. 2017;124:900-907.

Checklists have been highlighted as a cognitive aid to avoid omissions in both routine care and critical events. This commentary describes the development and testing of three critical event checklists in children's hospitals and provides implementation guidance to support their use.

Journal Article > Commentary

Medication safety in the neonatal intensive care unit: big measures for our smallest patients.

Rostas SE. J Perinat Neonatal Nurs. 2017;31:15-19.

Medication errors are common in the neonatal intensive care unit. This commentary outlines various strategies one teaching hospital has utilized to reduce risks of medication errors in this care setting, such as use of computerized provider order entry and smart pumps.

Journal Article > Commentary

Development of a pediatric adverse events terminology.

Gipson DS, Kirkendall ES, Gumbs-Petty B, et al. Pediatrics. 2017;139:e20160985.

Taxonomies help to consistently organize data and evidence for use in research. This commentary describes the development of a terminology specific to adverse events in children for use in various settings. The authors note that the tool will be continuously updated and is expected to mature over time.

Journal Article > Commentary

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.

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