Sharon Calaman

Changes in medical errors after implementation of a handoff program

BACKGROUND Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. METHODS We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. RESULTS In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. CONCLUSIONS Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

Development, implementation, and dissemination of the I-PASS handoff curriculum: A multisite educational intervention to improve patient handoffs

Patient handoffs are a key source of communication failures and adverse events in hospitals. Despite Accreditation Council for Graduate Medical Education requirements for residency training programs to provide formal handoff skills training and to monitor handoffs, well-established curricula and validated skills assessment tools are lacking. Developing a handoff curriculum is challenging because of the need for standardized processes and faculty development, cultural resistance to change, and diverse institution- and unit-level factors. In this article, the authors apply a logic model to describe the process they used from June 2010 to February 2014 to develop, implement, and disseminate an innovative, comprehensive handoff curriculum in pediatric residency training programs as a fundamental component of the multicenter Initiative for Innovation in Pediatric Education–Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs (I-PASS) Study. They describe resources, activities, and outputs, and report preliminary learner outcomes using data from resident and faculty evaluations of the I-PASS Handoff Curriculum: 96% of residents and 97% of faculty agreed or strongly agreed that the curriculum promoted acquisition of relevant skills for patient care activities. They also share lessons learned that could be of value to others seeking to adopt a structured handoff curriculum or to develop large-scale curricular innovations that involve redesigning firmly established processes. These lessons include the importance of approaching curricular implementation as a transformational change effort, assembling a diverse team of junior and senior faculty to provide opportunities for mentoring and professional development, and linking the educational intervention with the direct measurement of patient outcomes.

Putting the pediatrics milestones into practice: a consensus roadmap and resource analysis.

The Accreditation Council for Graduate Medical Education has partnered with member boards of the American Board of Medical Specialties to initiate the next steps in advancing competency-based assessment in residency programs. This initiative, known as the Milestone Project, is a paradigm shift from traditional assessment efforts and requires all pediatrics residency programs to report individual resident progression along a series of 4 to 5 developmental levels of performance, or milestones, for individual competencies every 6 months beginning in June 2014. The effort required to successfully make this shift is tremendous given the number of training programs, training institutions, and trainees. However, it holds great promise for achieving training outcomes that align with patient needs; developing a valid, reliable, and meaningful way to track residents’ development; and providing trainees with a roadmap for learning. Recognizing the resources needed to implement this new system, the authors, all residency program leaders, provide their consensus view of the components necessary for implementing and sustaining this effort, including resource estimates for completing this work. The authors have identified 4 domains: (1) Program Review and Development of Stakeholders and Participants, (2) Assessment Methods and Validation, (3) Data and Assessment System Development, and (4) Summative Assessment and Feedback. This work can serve as a starting point and framework for collaboration with program, department, and institutional leaders to identify and garner necessary resources and plan for local and national efforts that will ensure successful transition to milestones-based assessment.

How can we assure procedural competence in pediatric residents in an era of diminishing opportunities? The answer is simulation-based training.

All rights reserved. 10.1016/j.jpeds.2010.02.058 xternal forces have greatly modified the learning environment of pediatric trainees. Restrictions of duty hours decrease the amount of time trainees spend in the clinical environment, reducing exposure to procedures and emergency situations. Consequentially, work compression and increasing complexity of patients’ problems have relegated procedures to a low priority. Patient safety initiatives have led to the creation of rapid response teams designed to take over care in an emergency, further decreasing trainee learning and leadership opportunities. As opportunities become limited, residents are competing with each other for experience. The increasing presence of attending physicians and the use of allied health providers contribute further to decrements in resident autonomy and sense of patient ownership. Fewer available ‘‘practice’’ hours are juxtaposed with increasing demands for documentation of procedural competency (as mandated by both the Pediatric Review Committee and Joint Commission on Accreditation of Healthcare Organizations). The net negative effect cannot be underestimated in pediatrics. Pediatric procedural skills and decision making have unique learning challenges as a child’s anatomy, physiology, and behavior all vary by age. Endotracheal intubation of an infant is different from intubation of a child. Cardiac arrests are rare in pediatrics—life-threatening events more likely begin as unrecognized respiratory emergencies that progress to cardiac arrest. The skill of recognizing an impending event is as important as the skills to manage the emergency. When that emergency occurs, competence in both procedural and critical thinking skills of responders is crucial for optimal outcomes. Nadel in 2000 surveyed pediatric residents and found that 44% of pediatric level-3 residents had never led a resuscitation event. The environment in the 2010s will have further decrements in trainee opportunities, practice, and skill. Together, these influences create what Weinstock, et al have referred to as the ‘‘pediatric training paradox.’’ There is inadequate clinical volume exposure for trainees to ensure optimal patient outcomes. Mastery of the management of medical crises requires teamwork, knowledge and technical skills, and opportunities for deliberate, rather than ‘‘accidental,’’ practice. Deliberate practice affords the learner a task with well-defined goals, a process for feedback, and opportunities for repetition to achieve expertise. Simulation can be the educational vehicle for this process. Simulation recreates events and conditions that may occur in actual patient encounters. Used equipment varies in fidelity. It can be as simple as an ‘‘intubation head’’ or as complex as a human patient simulator (eg, computer-driven mannequin with vital sign changes and physical examination findings) directed by the exercise objectives. The use of simulation is well established in many nonmedical industries, such as the military, the airline industry, and the nuclear power industry. As in medicine, the tasks require high reliability of skills when personnel react to life-threatening emergencies. The cognitive processes and experience of repetition and variation must be developed in a safe arena in which lives are not at stake. Nelson, et al described successful use of simulation to train counselors to deal with emergencies in a camp setting. The camp staff practiced simulations with the automated external defibrillator. Subsequently, a camper was struck by lightening and was successfully resuscitated by staff using the automated external defibrillator. One staff member noted that despite never having managed an actual cardiac arrest, ‘‘I knew what to do, because I’ve already done it a hundred times.’’ The extension of this technique to medicine makes intuitive sense. Simulation is not limited to procedural skills but can also powerfully engage the learner in the cognitive processes necessary to recognize a situation, sort options for intervention, act, and observe the consequences in real time. This far outstrips merely making differential diagnoses. Simulation is a safe, learner-driven environment that allows for the practice of critical thinking, team interaction, leadership, and communication skills. Simulation allows a trainee to enter a real-life situation (eg, in an intensive care unit or the general practice of pediatrics) with practiced skills, instead of the patient encounter or systems crisis being the first opportunity to acquire those skills. Simulation can bridge the experience gap and change chance encounters into deliberate practice. Satisfactory completion of a certain number of curricular block rotations pales as evidence of competence in comparison with cumulative achievement through simulation. The broadest application of simulation in medicine thus far has been in anesthesiology, as pioneered by Gaba. Simulation is nascent in pediatrics. Halamek et al developed a neonatal resuscitation course using both traditional and simulated

Placing Faculty Development Front and Center in a Multisite Educational Initiative: Lessons From the I-PASS Handoff Study

From the University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Dr O’Toole); University of California San Francisco School of Medicine, Benioff Children’s Hospital, San Francisco, Calif (DrsWest andRosenbluth); HarvardMedical School, Boston Children’s Hospital (Drs Starmer, Landrigan, and Sectish); Uniformed Health Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Md (Drs Yu, Hepps, and Lopreiato); Drexel University College of Medicine, St. Christopher’s Hospital for Children, Philadephia, PA (Drs Calaman and Spector); and Brigham and Women’s Hospital, Boston, Mass (Dr Landrigan) Dr Landrigan is supported by the Children’s Hospital Association for his work as an Executive Council member of the PRIS Network. He has also received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for delivering lectures on sleep deprivation, physician performance, handoffs, and safety. The other authors declare no conflicts of interest. Address correspondence to Jennifer K. O’Toole, MD, MEd, Cincinnati Children’s Hospital Medical Center/Division of Hospital Medicine, 3333 Burnet Ave, MLC 5018, Cincinnati, OH 45229-3039 (e-mail: Jennifer.otoole@cchmc.org).

A case report of clinically significant coagulopathy associated with aerosolized heparin and acetylcysteine therapy for inhalation injury.

A case report of clinically significant coagulopathy associated with aerosolized heparin and acetylcysteine therapy for inhalation injury Arun Chopra , Brooke Burkey *, Sharon Calaman a Drexel University College of Medicine, Section of Critical Care, St. Christopher’s Hospital for Children, Philadelphia, PA, United States Drexel University College of Medicine, Section of Plastic and Reconstructive Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA, United States b u r n s 3 7 ( 2 0 1 1 ) e 7 3 – e 7 5

The Creation of Standard-Setting Videos to Support Faculty Observations of Learner Performance and Entrustment Decisions.

Entrustable professional activities (EPAs) provide a framework to standardize medical education outcomes and advance competency-based assessment. Direct observation of performance plays a central role in entrustment decisions; however, data obtained from these observations are often insufficient to draw valid high-stakes conclusions. One approach to enhancing the reliability and validity of these assessments is to create videos that establish performance standards to train faculty observers. Little is known about how to create videos that can serve as standards for assessment of EPAs. The authors report their experience developing videos that represent five levels of performance for an EPA for patient handoffs. The authors describe a process that begins with mapping the EPA to the critical competencies needed to make an entrustment decision. Each competency is then defined by five milestones (behavioral descriptors of performance at five advancing levels). Integration of the milestones at each level across competencies enabled the creation of clinical vignettes that were converted into video scripts and ultimately videos. Each video represented a performance standard from novice to expert. The process included multiple assessments by experts to guide iterative improvements, provide evidence of content validity, and ensure that the authors successfully translated behavioral descriptions and vignettes into videos that represented the intended performance level for a learner. The steps outlined are generalizable to other EPAs, serving as a guide for others to develop videos to train faculty. This process provides the level of content validity evidence necessary to support using videos as standards for high-stakes entrustment decisions.

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. Objective To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. Design, Setting, and Participants We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; &kgr;, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. Main Outcomes and Measures Error and AE rates. Results Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates. Conclusions and Relevance Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Pharmacokinetics of Continuous-Infusion Meropenem for the Treatment of Serratia marcescens Ventriculitis in a Pediatric Patient

Neither guidelines nor best practices for the treatment of external ventricular drain (EVD) and ventriculoperitoneal shunt infections exist. An antimicrobial regimen with a broad spectrum of activity and adequate cerebrospinal fluid (CSF) penetration is vital in the management of both EVD and ventriculoperitoneal infections. In this case report, we describe the pharmacokinetics of continuous‐infusion meropenem for a 2‐year‐old girl with Serratia marcescens ventriculitis. A right frontal EVD was placed for the management of a posterior fossa mass with hydrocephalus and intraventricular hemorrhage. On hospital day 6, CSF specimens were cultured, which identified a pan‐sensitive Serratia marcescens with an initial cefotaxime minimum inhibitory concentration of 1 μg/ml or less. The patient was treated with cefotaxime monotherapy from hospital days 6 to 17, during which her CSF cultures and Grams stain remained positive. On hospital day 26, Serratia marcescens was noted to be resistant to cefotaxime (minimum inhibitory concentration > 16 μg/ml), and the antimicrobial regimen was ultimately changed to meropenem and amikacin. Meropenem was dosed at 40 mg/kg/dose intravenously every 6 hours, infused over 30 minutes, during which, simultaneous serum and CSF meropenem levels were measured. Meropenem serum and CSF levels were measured at 2 and 4 hours from the end of the infusion with the intent to perform a pharmacokinetic/pharmacodynamic analysis. The resulting serum meropenem levels were 12 μg/ml at 2 hours and “undetectable” at 4 hours, with CSF levels of 1 and 0.5 μg/ml at 2 and 4 hours, respectively. On hospital day 27, the meropenem regimen was changed to a continuous infusion of 200 mg/kg/day, with repeat serum and CSF meropenem levels measured on hospital day 33. The serum and CSF levels were noted to be 13 and 0.5 μg/ml, respectively. The serum level of 13 μg/ml corresponds to an estimated meropenem clearance from the serum of 10.2 ml/kg/minute. Repeat meropenem levels from the serum and CSF on hospital day 37 were 15 and 0.5 μg/ml, respectively. After instituting the continuous‐infusion meropenem regimen, only three positive CSF Grams stains were noted, with the CSF cultures remaining negative. The continuous‐infusion dosing regimen allowed for 100% probability of target attainment in the serum and CSF and a successful clinical outcome.

Reflect, Advise, Plan: Faculty-Facilitated Peer-Group Mentoring to Optimize Individualized Learning Plans.

THE CONCEPT OF self-directed, lifelong learning is a highly regarded tenet of medical professionalism. Accordingly, the Accreditation Council for Graduate Medical Education (ACGME) has recently adopted a milestone to assess a learner’s ability to “identify strengths, deficiencies, and limits in one’s knowledge and expertise.” Many experts believe that self-assessment and the ability to be a self-directed learner are not innate, but rather skills that need to be learned through practice and training. Individualized learning plans (ILPs) represent a unique opportunity to develop residents’ skills in self-assessment and self-directed learning. In fact, the ACGME requires all pediatric residency programs to provide “a system to assist residents in [the] ILP development process, including: faculty mentorship to help residents create learning goals; and, systems for tracking and monitoring progress toward completing the ILP”. Unfortunately, residents often struggle to develop attainable goals, especially within competencies that are less integrated into everyday training, such as systemsbased practices. Effective mentoring strategies are essential to the success of the resident ILP development process. Academic faculty are typically most familiar with the dyadic model of mentoring, in which an experienced mentor is paired with a less-practiced mentee on the basis of common interests. The dyadic model has drawbacks, including time constraints, limitations of one mentor’s individual perspective and skill sets, and incongruent expectations between mentor and mentee. Consequently, many innovative mentoring models are now appearing in the literature and might be more successful. Peer mentoring, a model in which the mentoring relationship occurs between individuals equal in experience and rank, is known to benefit the mentor and the mentee. Facilitated peer group mentoring (FPGM) is a subset of peer mentoring in which group members serve as peer mentors to each other while facilitated by a