Reducing Serious Safety Events and Priority Hospital-Acquired Conditions in a Pediatric Hospital with the Implementation of a Patient Safety Program

Phipps, Amber R.; Paradis, Melisa; Peterson, Kimberly A.; Jensen, Jill; Nielsen, Katie R.; Hall, Melanie; Simonsen, Kari; Norton, Bridget M.

doi:10.1016/j.jcjq.2017.12.006

Cited by 13 publications

(18 citation statements)

References 7 publications

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“…Although several previous studies related to ICTR have been conducted, these studies investigated the benefits of incorporating leadership rounding into infection prevention and focused on the association between infection control activities with rounding and one specific type of infection [2,[4][5][6][7][8]. These assessments indicated that ICTR was successful in the studied context; nonetheless, these studies lack a comprehensive perspective on the mechanisms of rounding.…”

Section: Discussionmentioning

confidence: 99%

Scope of a weekly infection control team rounding in an acute-care teaching hospital: a pilot study

Jeong

Kim

Lee

et al. 2020

Antimicrob Resist Infect Control

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Regular and well-organized inspection of infection control is an essential element of an infection control program. The aim of this study was to identify the functional scope of weekly infection control team rounding (ICTR) in an acute care hospital. We conducted weekly ICTR between January 18 and December 26, 2018 to improve the compliance to infection control and prevention measures at a 734-bed academic hospital in the Republic of Korea and analyzed the results retrospectively. We categorized the results into five groups: "well maintained," "improvement needed," "long-term support, such as space or manpower, needed," "not applicable," or "could not be observed". A total of nine categories and 85 sub-elements of infection control and prevention practices were evaluated. The median number of infection control team (ICT) visits per department was 7 (interquartile range [IQR]: 6-7). The ICT assessed a median of 16 elements (IQR: 12-22), and a total of 7452 results were obtained. Of those, 75% were monitored properly, 22% were "not applicable", and 4% were difficult to observe. The most common practices that were difficult to observe were strategies to prevent catheter-related surgical site infections, pneumonia, and occupationally acquired infections as well as injection safety practices. Although the ICTR was able to maintain regular visits to each department, further strategies beyond regular ICTR are needed to reduce category of "could not observed". This pilot study may provide an important reference for institutional infection prevention practices as it is the first study to investigate the functional coverage of ICTR.

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Section: Discussionmentioning

confidence: 99%

Scope of a weekly infection control team rounding in an acute-care teaching hospital: a pilot study

Jeong

Kim

Lee

et al. 2020

Antimicrob Resist Infect Control

View full text Add to dashboard Cite

show abstract

“…Although several previous studies related to ICTR have been conducted, these studies investigated the bene ts of incorporating leadership rounding into infection prevention and focused on the association between infection control activities with rounding and one speci c type of infection. 2,4,5,6,8,9 These assessments indicated that ICTR was successful in the studied context; nonetheless, these studies lack a comprehensive perspective on the mechanisms of rounding. In contrast, our study evaluated monitoring of infection control activities based on the entire infection prevention protocol, with a grade-based assessment of infection control activities.…”

Section: Discussionmentioning

confidence: 99%

Scope of a weekly infection control team rounding in an acute-care teaching hospital: a pilot study

Jeong

Kim

Lee

et al. 2020

Preprint

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Regular and well-organized inspection of infection control is an essential element of an infection control program. The aim of this study was to identify the functional scope of weekly infection control team rounding (ICTR) in an acute care hospital. We conducted weekly ICTR between January 18 and December 26, 2018 to improve the compliance to infection control and prevention measures at a 734-bed academic hospital in the Republic of Korea and analyzed the results retrospectively. We categorized the results into five groups: “well maintained,” “improvement needed,” “long-term support, such as space or manpower, needed,” “not applicable,” or “could not be observed”. A total of nine categories and 85 sub-elements of infection control and prevention practices were evaluated. The median number of infection control team (ICT) visits per department was 7 (interquartile range [IQR]: 6-7). The ICT assessed a median of 16 elements (IQR: 12-22), and a total of 7,452 results were obtained. Of those, 75% were monitored properly, 22% were “not applicable”, and 4% were difficult to observe. The most common practices that were difficult to observe were strategies to prevent catheter-related surgical site infections, pneumonia, and occupationally acquired infections as well as injection safety practices. Although the ICTR was able to maintain regular visits to each department, further strategies beyond regular ICTR are needed to reduce category of “could not observed”. This pilot study may provide an important reference for institutional infection prevention practices as it is the first study to investigate the functional coverage of ICTR.

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“…One benefit to a standardized and quantitative approach is that it may facilitate pooling patient safety event data for peer benchmarking. [11][12][13][14] At our institution, we collectively shared concern that our efforts to track and trend HIT-related safety events were hampered by the absence of a mechanism to systematically classify and organize HIT-related events. We hypothesized that the presence of a structured taxonomy for patient safety events would facilitate consistent and reliable categorization of patient safety events with the aim of furthering patient safety and quality improvement goals.…”

Section: Background and Significancementioning

confidence: 99%

“…Recently, institutions have shown increased interest in pooling patient safety event data for peer benchmarking. [11][12][13][14] There are several barriers to openly and transparently sharing data, including concerns regarding litigation and impact on an institution's reputation. 43 Patient safety experts are increasingly calling for an open and collaborative approach to reducing the incidence of patient harm, since solutions will require collaboration between end users, organizations, and EHR vendors.…”

Section: Utility Of Patient Safety Event Taxonomiesmentioning

confidence: 99%

Development of a Taxonomy for Medication-Related Patient Safety Events Related to Health Information Technology in Pediatrics

et al. 2020

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Background Although electronic health records (EHRs) are designed to improve patient safety, they have been associated with serious patient harm. An agreed-upon and standard taxonomy for classifying health information technology (HIT) related patient safety events does not exist. Objectives We aimed to develop and evaluate a taxonomy for medication-related patient safety events associated with HIT and validate it using a set of events involving pediatric patients. Methods We performed a literature search to identify existing classifications for HIT-related safety events, which were assessed using real-world pediatric medication-related patient safety events extracted from two sources: patient safety event reporting system (ERS) reports and information technology help desk (HD) tickets. A team of clinical and patient safety experts used iterative tests of change and consensus building to converge on a single taxonomy. The final devised taxonomy was applied to pediatric medication-related events assess its characteristics, including interrater reliability and agreement. Results Literature review identified four existing classifications for HIT-related patient safety events, and one was iteratively adapted to converge on a singular taxonomy. Safety events relating to usability accounted for a greater proportion of ERS reports, compared with HD tickets (37 vs. 20%, p = 0.022). Conversely, events pertaining to incorrect configuration accounted for a greater proportion of HD tickets, compared with ERS reports (63 vs. 8%, p < 0.01). Interrater agreement (%) and reliability (kappa) were 87.8% and 0.688 for ERS reports and 73.6% and 0.556 for HD tickets, respectively. Discussion A standardized taxonomy for medication-related patient safety events related to HIT is presented. The taxonomy was validated using pediatric events. Further evaluation can assess whether the taxonomy is suitable for nonmedication-related events and those occurring in other patient populations. Conclusion Wider application of standardized taxonomies will allow for peer benchmarking and facilitate collaborative interinstitutional patient safety improvement efforts.

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Reducing Serious Safety Events and Priority Hospital-Acquired Conditions in a Pediatric Hospital with the Implementation of a Patient Safety Program

Abstract: The No Harm Patient Safety Program was interwoven into the organization's strategic mission and values, and key messaging was used to purposefully tie the many interventions being implemented back to it. These interventions were associated with improvements in patient safety outcomes.

Cited by 13 publications

References 7 publications

Scope of a weekly infection control team rounding in an acute-care teaching hospital: a pilot study

Scope of a weekly infection control team rounding in an acute-care teaching hospital: a pilot study

Scope of a weekly infection control team rounding in an acute-care teaching hospital: a pilot study

Development of a Taxonomy for Medication-Related Patient Safety Events Related to Health Information Technology in Pediatrics

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