Michael S. Leonard

Risk Reduction for Adverse Drug Events Through Sequential Implementation of Patient Safety Initiatives in a Children's Hospital

BACKGROUND. Medication management is a complex, multifaceted system. Prescribing errors occur upstream in the process, and as such, their effects can be perpetuated, and sometimes even exacerbated, in subsequent steps. These errors place patients at risk of adverse drug events. Children, especially young infants, are at particular risk because of their size, unique physiology, and immature ability to metabolize drugs. OBJECTIVE. The purpose of this study was to reduce the risk of harm to children resulting from prescribing errors. METHODS. We sequentially implemented patient safety initiatives over a 1-year time frame at a pediatric tertiary care academic facility. The initiatives included an educational Web site with competency examination, distribution of a personal digital assistant-based standardized dosing reference, a zero-tolerance policy for incomplete or incorrect medication orders, prescriber performance feedback, and presentation of outcome data at citywide grand rounds. A total of 8718 orders were collected and analyzed to assess the impact of these initiatives. RESULTS. The absolute risk reduction from prescribing errors was 38 per 100 orders, with a relative risk reduction of 49%. Web-based education with point-of-care drug references and a zero-tolerance policy for incomplete or incorrect orders were most effective in decreasing potential adverse drug events. Documentation of appropriate weight-based dosing and indication for therapy increased by 24% and 42%, respectively. CONCLUSIONS. Process-improvement initiatives focusing on prescriber education and behavior modification can reduce the risk of harm to pediatric patients from prescribing errors.

Patient safety and quality improvement: an overview of QI.

It is important for pediatric providers to be involved in quality improvement (QI) activities to improve children’s health outcomes.• The Model for Improvement asks several key questions related to a process, then uses Plan-Do-Study-Act(PDSA) cycles to implement, test, and spread changes.• Lean and Six Sigma methodologies can improve quality by increasing workflow efficiency and decreasing variation.• Root cause analysis (RCA) is a retrospective quality tool that helps determine factors contributing to errors and adverse events, so that improvements can be implemented.• Failure modes and effects analysis (FMEA) isa prospective quality tool that anticipates system vulnerabilities and helps develop risk reduction strategies.• Evidence-based interventions, such as best-practice guidelines, promote standardization and reduce errors and adverse events, especially in high-risk health-care settings.• Team training can improve communication and situational awareness to create a safer health-care environment.

Patterns and changes in prescriber attitudes toward PDA prescription-assistive technology

CONTEXT Medication error prevention is a priority for the U.S. healthcare system in the 21st century. Use of technology is considered by some as critical to achieve this goal. Knowledge of the attitudinal barriers to such adoption, however, is limited. OBJECTIVE To determine the attitudes of frontline prescriber clinicians towards technology in general, and PDAs specifically, before and after introduction of a PDA in the clinical setting of medication prescribing. DESIGN A pre- and post-intervention web-based survey, 12-14 months apart. SETTING Academic tertiary care childrens hospital. PARTICIPANTS Total of 244 prescriber clinicians. INTERVENTION Distribution of a PDA with pediatric-specific medication prescribing information after completion of an on-line medication safety certification and other safety focused educational sessions. MAIN OUTCOME MEASURES Ratings (5-point Likert scale) reflecting perceptions and attitudes towards technology in general and technology in medical settings along with self-reported usage of the PDA for Rx. RESULTS Early Adopters and Late Adopters were identified statistically, and the group membership reflected their prior exposure to and ownership of other technologies. Early Adopters tended to be younger and less experienced clinically (e.g., residents) and more frequent owners and users of technology. Early Adopters expressed significantly more favorable attitudes toward technology and PDAs on both pre- to post-intervention survey occasions. They also utilized the PDA for Rx more often than LAs. Interestingly, PDA use for Early Adopters was based on its ease of use, while PDA use among later adopters was based on its clinical usefulness. CONCLUSIONS Provision of point of care information using PDAs and a user-friendly, pediatric-specific medication information software package did not positively affect the attitudes of prescriber clinicians among those already favorable toward technology. However, a significant change was found among those with initially less favorable attitudes. Organizations need to understand the nature of both Early and Late Adopters and plan appropriately for managing the respective needs and expectations when potentially beneficial technologies are introduced. In order to ensure the success of an implementation, the training and supportive interventions need to be carefully designed and specifically catered to the personality-based outcome expectations of the prescriber.

Patient Safety and Quality Improvement: Medical Errors and Adverse Events

1. Michael S. Leonard, MD, MS* 1. *Chief Quality & Safety Officer for Childrens Services, Associate Professor of Pediatrics, University of Rochester Medical Center, Rochester, NY. After completing this article, readers should be able to: 1. Define terms commonly used in patient safety discourse. 2. Describe the scope of medical errors and adverse events, focusing on medication-related issues. 3. Identify barriers to improving patient safety. 4. Address disclosure of medical errors and adverse events. 5. Review principles and practices that can reduce the risk of harm to patients. This is the first in a series of articles to review the topics of patient safety and quality improvement in pediatrics. Patient safety is a subject that traverses all medical specialties and affects every health-care professional. The attention to medical errors and adverse events as well as the resultant literature has grown exponentially over the past decade. A number of practicing physicians, however, remain unaware of the extent of the problem, the impact on patients, and the burden on the health-care system. Many also are unfamiliar with strategies to reduce the risk of harm. It is important to note that definitions used in patient safety can vary across studies, between organizations, and over time. A medical error, as defined by the Institute of Medicine (IOM), is “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” (1)(2) It is a mistake in action or judgment. A medical error must be distinguished from an adverse event, which is “an injury caused by medical management rather than by the underlying disease or condition of the patient.” An adverse event results in harm to the patient. Not all medical errors lead to adverse events. In fact, most do not. A medication error is the most common …

Infantile gastroesophageal reflux in a hospital setting

BackgroundGastroesophageal reflux is a common diagnosis in infants. Yet, there is no information on the demographics of those hospitalized with reflux. The aim of this study is to describe the demographics of children with gastroesophageal reflux discharged from the hospital during the first two years of life.MethodsRetrospective chart review of children aged 0–2 years discharged between January 1, 1995 and December 31, 1999 with a diagnosis of reflux documented in their hospital chart prior to 12 months of age.ResultsReflux was the seventh most common reason for hospitalization. About 50% of subjects with reflux had multiple hospitalizations. Of the 1,096 infants diagnosed with reflux about half were born prematurely. Reflux was the primary diagnosis for 21% of all infants; 10% of those born prematurely. The average length of stay for the subjects was longer than the hospital average. African Americans, 2.4% of the population, accounted for 29% of discharges. Caucasians, 86% of the population, were 66% of discharges. 21.8% of African Americans and 68.3% of Caucasians were diagnosed with reflux. 35% of mothers smoked, 27% worked and 48% had public insurance, compared to 22.2%, 57%, and 24% respectively of females in the general population.ConclusionReflux is a common discharge diagnosis. Children who have primary reflux have longer than average hospital stays. About half had multiple admissions. Mothers of children with reflux are more likely to be less educated, receive public insurance, smoke, and be unemployed than the general female population in Western New York. Although African American children were disproportionately hospitalized, they were less likely to be diagnosed with reflux.

Interobserver reliability of attending physicians and bedside nurses when using an inpatient paediatric respiratory score.

AIMS AND OBJECTIVES This study aimed to determine the interobserver reliability between bedside nurses and attending physicians for a paediatric respiratory score as part of an asthma Integrated Care Pathway implementation. BACKGROUND An Integrated Care Pathway is one approach to improving quality of care for children hospitalised with asthma. Prior to implementation of the integrated care pathway, it was necessary to train nursing staff on the use of a respiratory assessment tool and to evaluate the interobserver reliability use of this tool. DESIGN Prospective study using a convenience sample of children hospitalised for a respiratory illness in an academic medical centre. METHODS The respiratory assessment used was the Paediatric Asthma Score. Bedside nurse-attending physician (27 different RNs and three attending paediatric hospitalists) pairs performed 71 simultaneous patient assessments on 20 patients. Intraclass correlation coefficient and kappa statistics were used to assess interobserver reliability. RESULTS The overall intraclass correlation coefficient was nearly perfect where κ = 0·95, 95% CI (0·92, 0·97) and overall kappa for reliability based on clinically relevant score breakpoints was also high with κ = 0·82, 95% CI (0·75, 0·90). The majority of subgroup analyses revealed substantial to almost perfect agreement across a variety of diagnoses, age ranges, and individual score components. CONCLUSIONS Bedside nurses, with support and training from attending physicians, can perform respiratory assessments that agree almost perfectly with those of attending physicians. RELEVANCE TO CLINICAL PRACTICE The use of an Integrated Care Pathway allows for optimal interprofessional collaboration between bedside nurses and attending physicians.

Tempering pediatric hospitalist supervision of residents improves admission process efficiency without decreasing quality of care

BACKGROUND Many academic pediatric hospital medicine (PHM) divisions have recently increased in-house supervision of residents, often providing 24/7 in-house attending coverage. Contrary to this trend, we removed mandated PHM attending input during the admission process. We present an evaluation of this process change. METHODS This cohort study compared outcomes between patients admitted to the PHM service before (July 1, 2011-September 30, 2011) and after (July 1, 2012-September 30, 2012) the process change. We evaluated time from admission request to inpatient orders, length of stay (LOS), frequency of change in antibiotic choice, and rapid response team (RRT) calls within 24 hours of admission. Data were obtained via chart abstraction and from administrative databases. Wilcoxon rank sum and Fisher exact tests were used for analysis. RESULTS We identified 182 and 210 admissions in the before and after cohorts, respectively. Median time between emergency department admission request and inpatient orders was significantly shorter after the change (123 vs 62 minutes, P < 0.001). We found no significant difference in LOS, the number of changes to initial resident antibiotic choice, standard of care, or RRTs called within the first 24 hours of admission. CONCLUSION Removing mandated attending input in decision making for PHM admissions significantly decreased time to inpatient resident admission orders without a change in measurable clinical outcomes.

Patient Safety and Quality Improvement: Reducing Risk of Harm.

Most medical errors and preventable adverse events represent failures of complex systems. Pediatric clinicians must ensure a safe environment for health-care delivery to children. To do so, they must recognize risk factors for errors and adverse events; ensure effective communication with patients, parents, and colleagues; heighten situation awareness; develop high-functioning, high-reliability teams; implement and employ technology carefully; and provide integrated, ongoing education to trainees.

Proportional Distribution of Patient Satisfaction Scores by Clinical Service The PRIME Model

The Proportional Responsibility for Integrated Metrics by Encounter (PRIME) model is a novel means of allocating patient experience scores based on the proportion of each physicians involvement in care. Secondary analysis was performed on Hospital Consumer Assessment of Healthcare Providers and Systems surveys from a tertiary care academic institution. The PRIME model was used to calculate specialty-level scores based on encounters during a hospitalization. Standard and PRIME scores for services with the most inpatient encounters were calculated. Hospital medicine had the most discharges and encounters. The standard model generated a score of 74.6, while the PRIME model yielded a score of 74.9. The standard model could not generate a score for anesthesiology due to the lack of returned surveys, but the PRIME model yielded a score of 84.2. The PRIME model provides a more equitable method for distributing satisfaction scores and can generate scores for specialties that the standard model cannot.

A 14-Year-Old Boy With Mycoplasma pneumoniae–Associated Mucositis and Intracranial Hypertension

A previously healthy 14-year-old boy was admitted with mucositis, genital lesions, and difficulty with urination. Two weeks prior to admission, the patient had upper respiratory symptoms including cough and congestion. Amoxicillin was prescribed for presumed sinusitis, but due to persistence of the cough, wheezing, and development of fevers, was switched to amoxicillin-clavulanate. He was also started on albuterol and prednisone for suspected bronchitis. Three days prior to admission, he developed sores under his tongue and on his lips. At this time, a chest x-ray was concerning for pneumonia; his antibiotic was switched to azithromycin. One day prior to admission, the patient developed lesions on his scrotum and had dysuria. On the day of admission, he presented with worsening symptoms and inability to void due to pain. Review of systems was positive for fevers (resolved 3 days prior to admission), scleral injection, cough, congestion, mouth sores, odynophagia, genital lesions, dysuria, decreased appetite, and constipation. Pertinent negatives included no vision changes, difficulty breathing, chest pain, vomiting, diarrhea, joint pain, or gross hematuria. The patient denied history of sexual activity. On admission, the patient had a temperature of 37°C, pulse of 86 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 108/72 mm Hg, and SpO 2 of 96% in room air. He was ill-appearing but not toxic. His sclerae were injected bilaterally. Lips were erythematous with ulcerations. Buccal mucosa appeared edematous with petechiae. Exudate was present on the hard and soft palates. Neck was supple. Cardiac exam was notable for a I/VI systolic murmur at the left upper sternal border. Lungs had faint crackles in the right lower lobe with no wheezing. Abdomen was soft with normal bowel sounds and no tenderness or hepatosplenomegaly. Genital exam was notable for multiple fluid-filled lesions on the scrotum and one at the urethral opening. There was a fine erythematous papular rash on the patient’s back, a few areas on his abdomen, and on the ventral aspect of his upper extremities bilaterally (see Figure 1 and 2). In the emergency department, the patient was given morphine and ibuprofen for pain, 2 normal saline intravenous boluses, and lidocaine 2% gel for voiding. Labs were significant for a white blood cell count of 14 200 cells/μL with 4% bands, elevated C-reactive protein of 23 mg/L, elevated erythrocyte-sedimentation rate of 48 mm/ hour, and an unremarkable urinalysis. Blood cultures were negative at 48 hours. A respiratory viral panel was negative. A sampling of fluid from the genital lesions was negative for herpes simplex virus via Tzanck smear and polymerase chain reaction (PCR; types 1 and 2). Serum electrolytes, blood urea nitrogen, serum creatinine, and liver function tests were normal. He was admitted to the hospital for further evaluation and management. Dermatology was consulted and agreed with the primary team’s diagnosis of likely Mycoplasma pneumoniae– associated mucositis (MPAM). They recommended azithromycin be continued for a 10-day total course. The patient was also started on a second 5-day course of prednisone. Ophthalmology was consulted to evaluate for iritis as Behçet’s disease was in the initial differential diagnosis. The patient was found to have bilateral papillitis and papilledema. Rheumatology was consulted to evaluate for Behçet’s disease, and felt his constellation of symptoms were not consistent. A brain magnetic resonance imaging (MRI)/magnetic resonance venography (MRV) to further investigate the eye findings revealed a partially empty sella and narrowed transverse sinuses bilaterally. A Neurology consult did not identify neurologic involvement beyond the papillitis. 570615 CPJXXX10.1177/0009922815570615Clinical PediatricsWinikor et al research-article2015