Safety II: A Novel Approach to Reducing Harm

Bartman, Thomas; Merandi, Jenna; Maa, Tensing; Cosgrove, Tara C.; Brilli, Richard J.

doi:10.1007/978-3-030-55829-1_12

Cited by 1 publication

(3 citation statements)

References 15 publications

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“…Subsequent interventions, including secondary/night rounds and improved compliance with bedside huddles for new watchers, have provided new venues to escalate patient care concerns for high-risk patients, allowing providers to "respond" or take action to prepare for or change the course of events. 16 After initial improvement, we have observed sustained improvement through 2021. As previously noted, there was a concurrent intervention with implementing a clinical deterioration algorithm on the ACCU in January 2021.…”

Section: Discussionmentioning

confidence: 84%

“…Some have proposed that the initial step necessary for proactive risk mitigation involves “recognition” of what might happen next, followed by “respond” and “learn.” 16 Recognition relies on one’s skill and experience, which may be lacking depending on multiple factors, including the level of training. A large proportion of front-line providers in our ACCU are categorial pediatric residents, most of whom are new to inpatient pediatric cardiology.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Improving Situational Awareness to Decrease Emergency ICU Transfers for Hospitalized Pediatric Cardiology Patients

Cosgrove,

Gajarski,

Dolan

et al. 2023

Pediatric Quality &Amp; Safety

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Introduction: Failure to recognize and mitigate critical patient deterioration remains a source of serious preventable harm to hospitalized pediatric cardiac patients. Emergency transfers (ETs) occur 10–20 times more often than code events outside the intensive care unit (ICU) and are associated with morbidity and mortality. This quality improvement project aimed to increase days between ETs and code events on an acute care cardiology unit (ACCU) from a baseline median of 17 and 32 days to ≥70 and 90 days within 12 months. Methods: Institutional leaders, cardiology-trained physicians and nurses, and trainees convened, utilizing the Institution for Healthcare Improvement model to achieve the project aims. Interventions implemented focused on improving situational awareness (SA), including a “Must Call List,” evening rounds, a visual management board, and daily huddles. Outcome measures included calendar days between ETs and code events in the ACCU. Process measures tracked the utilization of interventions, and cardiac ICU length of stay was a balancing measure. Statistical process control chart methodology was utilized to analyze the impact of interventions. Results: Within the study period, we observed a centerline shift in primary outcome measures with an increase from 17 to 56 days between ETs and 32 to 62 days between code events in the ACCU, with sustained improvement. Intervention utilization ranged from 87% to 100%, and there was no observed special cause variation in our balancing measure. Conclusions: Interventions focused on improving SA in a particularly vulnerable patient population led to sustained improvement with reduced ETs and code events outside the ICU.

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Section: Discussionmentioning

confidence: 84%

Section: Discussionmentioning

confidence: 99%