Susan Bostwick

Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.

OBJECTIVES. This study was conducted to determine the impact of a computerized physician order entry system with substantial decision support on the incidence and types of adverse drug events in hospitalized children. METHODS. A prospective methodology was used for the collection of adverse drug events and potential adverse drug events from all patients admitted to the pediatric intensive care and general pediatric units over a 6-month period. Data from a previous adverse drug event study of the same patient care units before computerized physician order entry implementation were used for comparison purposes. RESULTS. Data for 1197 admissions before the introduction of computerized physician order entry were compared with 1210 admissions collected after computerized physician order entry implementation. After computerized physician order entry implementation, it was observed that the number of preventable adverse drug events (46 vs 26) and potential adverse drug events (94 vs 35) was reduced. Reductions in overall errors, dispensing errors, and drug-choice errors were associated with computerized physician order entry. There were reductions in significant events, as well as those events rated as serious or life threatening, after the implementation of computerized physician order entry. Some types of adverse drug events continued to persist, specifically underdosing of analgesics. There were no differences in length of stay or patient disposition between preventable adverse drug events and potential adverse drug events in either study period. CONCLUSIONS. This study demonstrated that a computerized physician order entry system with substantive decision support was associated with a reduction in both adverse drug events and potential adverse drug events in the inpatient pediatric population. Additional system refinements will be necessary to affect remaining adverse drug events. Preventable events did not predict excess length of stay and instead may represent a sign, rather than a cause, of more complicated illness.

Intercepting Wrong-Patient Orders in a Computerized Provider Order Entry System

STUDY OBJECTIVE We evaluate the short- and long-term effect of a computerized provider order entry-based patient verification intervention to reduce wrong-patient orders in 5 emergency departments. METHODS A patient verification dialog appeared at the beginning of each ordering session, requiring providers to confirm the patients identity after a mandatory 2.5-second delay. Using the retract-and-reorder technique, we estimated the rate of wrong-patient orders before and after the implementation of the intervention to intercept these errors. We conducted a short- and long-term quasi-experimental study with both historical and parallel controls. We also measured the amount of time providers spent addressing the verification system, and reasons for discontinuing ordering sessions as a result of the intervention. RESULTS Wrong-patient orders were reduced by 30% immediately after implementation of the intervention. This reduction persisted when inpatients were used as a parallel control. After 2 years, the rate of wrong-patient orders remained 24.8% less than before intervention. The mean viewing time of the patient verification dialog was 4.2 seconds (SD=4.0 seconds) and was longer when providers indicated they placed the order for the wrong patient (4.9 versus 4.1 seconds). Although the display of each dialog took only seconds, the large number of display episodes triggered meant that the physician time to prevent each retract-and-reorder event was 1.5 hours. CONCLUSION A computerized provider order entry-based patient verification system led to a moderate reduction in wrong-patient orders that was sustained over time. Interception of wrong-patient orders at data entry is an important step in reducing these errors.

The Current and Ideal State of Mental Health Training: Pediatric Resident Perspectives

Phenomenon: Mental health (MH) problems are prevalent in the pediatric population, and in a setting of limited resources, pediatricians need to provide MH care in the primary medical home yet are uncomfortable doing so citing a lack of training during residency as one barrier. Approach: The purpose of this study is to describe pediatric residents’ experiences and perspectives on the current and ideal states of MH training and ideas for curriculum development to bridge this gap. A qualitative study using focus groups of pediatric residents from an urban academic medical center was performed. Audio recordings were transcribed and analyzed using a grounded theory approach. Findings: Twenty-six residents participated in three focus groups, which is when thematic saturation was achieved. The team generated five major themes: capabilities, comfort, organizational capacity, coping, and education. Residents expressed uncertainty at every step of an MH visit. Internal barriers identified included low levels of comfort and negative emotional responses. External barriers included a lack of MH resources and mentorship in MH care, or an inadequate organizational capacity. These internal and external barriers resulted in a lack of perceived capability in handling MH issues. In response, residents reported inadequate coping strategies, such as ignoring MH concerns. To build knowledge and skills, residents prefer educational modalities including didactics, experiential learning through collaborations with MH specialists, and tools built into patient care flow. Insights: Pediatric residency programs need to evolve in order to improve resident training in MH care. The skills and knowledge requested by residents parallel the American Academy of Pediatrics statement on MH competencies. Models of collaborative care provide similar modalities of learning requested by residents. These national efforts have not been operationalized in training programs yet may be useful for curriculum development and dissemination to enhance trainees’ MH knowledge and skills to provide optimal MH care for children.

The Role of Housestaff in Implementing Medication Reconciliation on Admission at an Academic Medical Center

Since 2006, the Joint Commission has required all hospitals to have a process in place for medication reconciliation (MR). Although it has been shown that MR decreases medical errors, achieving compliance has proven difficult for many health care institutions. This article describes a housestaff-championed intervention of a “hard stop” for on-admission MR orders that led to a statistically significant increase in compliance that was sustained at 6 months after intervention. Academic medical centers, which comprise large numbers of housestaff, can improve compliance with on-admission MR by engaging housestaff in the development of solutions and in communication to their peers, leading to sustained results.

The AAP resilience in the face of grief and loss curriculum

A career in pediatrics can bring great joy and satisfaction. It can also be challenging and lead some providers to manifest burnout and depression. A curriculum designed to help pediatric health providers acquire resilience and adaptive skills may be a key element in transforming times of anxiety and grief into rewarding professional experiences. The need for this curriculum was identified by the American Academy of Pediatrics Section on Medical Students, Residents and Fellowship Trainees. A working group of educators developed this curriculum to address the professional attitudes, knowledge, and skills essential to thrive despite the many stressors inevitable in clinical care. Fourteen modules incorporating adult learning theory were developed. The first 2 sections of the curriculum address the knowledge and skills to approach disclosure of life-altering diagnoses, and the second 2 sections focus on the provider’s responses to difficult patient care experiences and their needs to develop strategies to maintain their own well-being. This curriculum addresses the intellectual and emotional characteristics patient care medical professionals need to provide high-quality, compassionate care while also addressing active and intentional ways to maintain personal wellness and resilience.

Developing Leaders in Pediatric Graduate Medical Education: The APPD LEAD Program

From the Department of Pediatrics, University of South Alabama College of Medicine, Mobile, Alabama (Dr Trimm); Department of Medical Education, Phoenix Children’s Hospital, Phoenix, Arizona (Dr Caputo); Department of Pediatrics, Weill Cornell Medical College, New York, New York (Dr Bostwick); Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (Dr Frohna); Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor, Michigan (Dr Haftel); Division of Infectious Diseases, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia (Dr Waggoner-Fountain); and Department of Pediatrics, University of California, Davis, Sacramento, California (Dr Li) The authors declare that they have no conflict of interest. Address correspondence to Franklin Trimm,MD, Department of Pediatrics, 1700 Center St, University of South Alabama, USAChildren’s and Women’s Hospital, Mobile, AL 36604 (e-mail: rftrimm@health.southalabama.edu).

A Proposed Job Description for the Modern Division Director

All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2013.07.016 T he position of division director is constantly evolving and today it has become arguably one of the most demanding positions within an academic Department of Pediatrics, requiring many of the skills and attributes of the department chair. Edward Miller, MD, former Dean and Chief Executive Officer at Johns Hopkins, reflected on the qualities and skills he looked for when recruiting a department chairperson for Johns Hopkins Medicine. His list included people skills, financial management skills, ability to get the most out of faculty, accountability for faculty performance, humility, and openness to new ways of thinking as key characteristics for the next generation of academic program leaders. It would seem that these attributes are the skills required of a successful division director as well. Although some previous articles, including those referenced above, have reviewed the leadership skills of the academic division director for pediatric, medical, and surgical services, we were unable to find any works specifically identifying the attributes and expectations of the modern division director. Collectively, we have decades of experience leading major academic programs at leading medical centers, and have been challenged by the process of recruiting leaders for key divisions (G.L. and G.D.). This experience prompted us to define more clearly the roles and responsibilities of our division directors. What follows is a proposed “job description” for the modern division director that a Department of Pediatrics chair may use to help guide expectations during the recruiting process. Ultimately, the actual responsibilities will be influenced by the organizational structure of the department, school of medicine, and hospital, as well as by the available compensation for administrative time, division size, and internal organization.

Fostering the Career Development of Future Educational Leaders: The Success of the Association of Pediatric Program Directors Leadership in Educational Academic Development Program

A lthough the importance of educational leaders is emphasized in the program requirements set forth by the Accreditation Council of Graduate Medical Education, the process for developing those leaders has not been well described. Existing development programs have focused on educational scholarship and project driven curricula in an attempt to provide support for developing the scholarship of medical educators. In response to a lack of formal curricula for developing both educational scholarship and leadership skills in pediatric graduate medical education, the Association of Pediatric Program Directors (APPD) developed a 10-month program entitled Leadership in Educational Academic Development (LEAD) that was designed to “provide training for educators aspiring to develop the knowledge and skills needed to become leaders in medical education.” The multifaceted curriculum of APPD LEAD provides facilitated peer-mentorship for developing educational scholarship and emphasizes training in personal professional development, leadership training, and administrative skill development. The program is conducted over 3 sessions, focusing on the individual, their training program, and their interaction with others and is taught in a highly interactive format by the LEAD council, a group of experienced pediatric educators. We undertook this study to assess the change in leadership positions, scholarly productivity, and career development for the participants in the first 3 years of APPD LEAD. We analyzed characteristics of APPD LEAD participants at baseline (program entrance) and 3 years after program completion to describe changes in areas that are important for the professional development of leaders in pediatric medical education: new educational leadership positions; scholarly productivity; and national presence at educational meetings and national committee participation.

Implementing Emotional Debriefing in Pediatric Clinical Education

Challenging situations and intense emotions are inherent to clinical practice. Failure to address these emotions has been associated with health care provider burnout. One way to combat this burnout and increase resilience is participation in emotional debriefing. Although there are many models of emotional debriefings, these are not commonly performed in clinical practice. We provide a guide for implementing emotional debriefing training utilizing the American Academy of Pediatrics Resilience Curriculum into clinical training programs, with a focus on preparing senior residents and fellows to act as debriefing facilitators. Senior residents and fellows can provide in-the-moment emotional debriefing which allows for greater health care provider participation, including medical students and other pediatric trainees. Training of senior residents and fellows may allow more frequent emotional debriefing and in turn may help to improve the resilience of pediatricians when they face challenging situations in clinical practice.

Using Your Personal Mission Statement to INSPIRE and Achieve Success

From the Department of Pediatrics, University of California Davis, Sacramento (Dr Li), Calif; Departments of Pediatrics and Medicine, University ofWisconsin School of Medicine and Public Health, Madison (Dr Frohna),Wis; and Department of Pediatrics, Weill Cornell Medical College, New York, NY (Dr Bostwick) The authors report no conflicts of interest. Address correspondence to Su-Ting T. Li, MD, MPH, Department of Pediatrics, 2516 Stockton Blvd, Sacramento, CA 95817 (e-mail: sutli@ ucdavis.edu).