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Search results for "United States of America"

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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

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 > 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

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 > 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

Decreasing malpractice claims by reducing preventable perinatal harm.

Riley W, Meredith LW, Price R, et al. Health Serv Res. 2016;51(suppl 3):2453-2471.

Improving patient safety provides an opportunity to reduce malpractice claims and associated costs, particularly in higher risk clinical areas such as obstetrics. This study examined medical malpractice claims and cost data in the perinatal units of hospitals before and after implementation of safety interventions focused on decreasing perinatal harm. Interventions consisted largely of standardizing best practices and implementing team training. Investigators found that improving perinatal safety led to substantial reductions in both the frequency and total cost of malpractice claims. The role that the medical liability system plays in driving up health care costs and in promoting the practice of defensive medicine—which can lead to adverse events through unnecessary tests and procedures—was highlighted in a past WebM&M commentary.

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

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 > Commentary

Post-event debriefings during neonatal care: why are we not doing them, and how can we start?

Sawyer T, Loren D, Halamek LP. J Perinatol. 2016;36:415-419.

Debriefings after clinical adverse events present learning opportunities for the teams and organizations involved. This commentary explores why debriefings are not routinely conducted and provide strategies to address barriers to the use of debriefings as a standard component of neonatal care.

Journal Article > Study

Interventions to improve safe sleep among hospitalized infants at eight children's hospitals.

Kuhlmann S, Ahlers-Schmidt CR, Lukasiewicz G, Truong TM. Hosp Pediatr. 2016;6:88-94.

Neonatal hospital units do not always adhere to safe infant sleep practices. In this pre-post study, investigators found that implementing a bundled approach—which included staff education, safe sleep policies, designated storage carts in patient rooms, and parent education—led to improvements in safe sleep, though most children had at least one element of unsafe sleep present even in the post-intervention period. This demonstrates the challenge of implementing new patient safety practices.

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

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.

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