Medication Discrepancy Risk Factors for Pediatric Patients With Epilepsy at Hospital Admission.

BACKGROUND: Children with epilepsy are at increased risk of medication errors due to disease complexity and administration of time-sensitive medication. Errors frequently occur during transitions of care between home and hospital, a time when accuracy of medication history lists is difficult to ascertain. Adverse events likely from medication discrepancies underscore the importance of improving medication reconciliation upon inpatient intake. This quality improvement project was designed to evaluate and optimize the current medication history process in epileptic patients upon hospital admission at a pediatric academic hospital. METHODS: A retrospective chart review was conducted on 30 patients with epilepsy admitted in during April, July, and October 2018 to identify unintentional medication discrepancies among 6 sources: documented medication history, inpatient orders from the electronic medical record, outpatient clinic notes, inpatient history and admission document, phone message records, and external insurance claims. RESULTS: A total of 63% percent of patients had at least 1 unintentional medication discrepancy. Most discrepancies occurred with daily maintenance anticonvulsants (63%). The most common types were omission of medication history (31%) and inpatient order omissions (27%). The number of medication histories completed with at least 1 discrepancy varied across pharmacists, nurses, and physicians, yet differences were not statistically significant. CONCLUSIONS: Our study found a higher incidence of anticonvulsant discrepancies compared with previous studies. This quality improvement initiative identified the absence of a standardized process as the root cause for the high incidence of anticonvulsant discrepancies in pediatric patients with epilepsy at hospital admission.

A Project-based Curriculum for Driving Organization-wide Continuous Improvement.

BACKGROUND: Creating the capacity and capability for meaningful improvement in healthcare quality is a challenge many organizations face. Before 2012, Children's Mercy sponsored 20 leaders to obtain advanced improvement training from peer organizations. Recognizing an opportunity to build upon this momentum, we developed an organization-wide curriculum for teaching continuous improvement. METHODS: A steering committee was created in 2011 to define, advise, and oversee education in improvement science. We agreed upon a framework for improvement, a program name [Continuous Quality and Practice Improvement (CQPI)], and a phased curriculum development approach, beginning with a project/experiential learning based course (Team CQPI). Course evaluation for Team CQPI consisted of a standard evaluation of objectives, pre- and post-course assessment, qualitative feedback, and serial assessment of project progress using the Team Assessment Score (TAS). The curriculum committee monitored improvement. RESULTS: From 2012 to 2017, 297 people participated in the project-based course, completing a total of 83 projects. TAS improved throughout the 4-month project-based course, from an average starting score of 1 ("forming a team") to 2.7 ("changes tested"). The average TAS at 12 months following completion of the Team CQPI course was 3.5 ("improvement") out of 5. CONCLUSIONS: Development of a comprehensive curriculum for driving continuous improvement has resulted in a measurable change in TAS scores representative of local improvement efforts.

Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement Initiative.

BACKGROUND AND OBJECTIVES: Acute pharyngitis is a common diagnosis in ambulatory pediatrics. The Infectious Diseases Society of America (IDSA) clinical practice guideline for group A streptococcal (GAS) pharyngitis recommends strict criteria for GAS testing to avoid misdiagnosis and unnecessary treatment of children who are colonized with group A Streptococcus. We sought to improve adherence to the IDSA guideline for testing and treatment of GAS pharyngitis in a large community pediatrics practice. METHODS: The Model for Improvement was used, and iterative Plan-Do-Study-Act cycles were completed. The quality improvement project was approved for American Board of Pediatrics Part 4 Maintenance of Certification credit. Interventions included provider education, modification of existing office procedure, communication strategies, and patient and family education. Outcomes were assessed by using statistical process control charts. RESULTS: An absolute reduction in unnecessary GAS testing of 23.5% (from 64% to 40.5%) was observed during the project. Presence of viral symptoms was the primary reason for unnecessary testing. Appropriate antibiotic use for GAS pharyngitis did not significantly change during the project; although, inappropriate use was primarily related to unnecessary testing. At the end of the intervention period, the majority of providers perceived an improvement in their ability to communicate with families about the need for GAS pharyngitis testing and about antibiotic use. CONCLUSIONS: The majority of GAS pharyngitis testing in this practice before intervention was inconsistent with IDSA guideline recommendations. A quality improvement initiative, which was approved for Part 4 Maintenance of Certification credit, led to improvement in guideline-based testing for GAS pharyngitis.

Variability of surgical prophylaxis in penicillin-allergic children.

We retrospectively evaluated the effect of penicillin adverse drug reaction (ADR) labeling on surgical antibiotic prophylaxis. Cefazolin was administered in 86% of penicillin ADR-negative (-) and 28% penicillin ADR-positive (+) cases. Broad-spectrum antibiotic use was more common in ADR(+) cases and was more commonly associated with perioperative adverse drug events.

Surgical Site Infection Reduction by the Solutions for Patient Safety Hospital Engagement Network.

OBJECTIVE: Surgical site infections (SSIs) negatively affect patients and the health care system. National standards for SSI prevention do not exist in pediatric settings. We sought to reduce SSI-related harm by implementing a prevention bundle through the Solutions for Patient Safety (SPS) national hospital engagement network. METHODS: Our study period was January 2011 to December 2013. We formed a national workgroup of content and quality improvement experts. We focused on 3 procedure types at high risk for SSIs: cardiothoracic, neurosurgical shunt, and spinal fusion surgeries. We used the Model for Improvement methodology and the Centers for Disease Control and Prevention SSI definition. After literature review and consultation with experts, we distributed a recommended bundle among network partners. Institutions were permitted to adopt all or part of the bundle and reported local bundle adherence and SSI rates monthly. Our learning network used webinars, discussion boards, targeted leader messaging, and in-person learning sessions. RESULTS: Recommended bundle elements encompassed proper preoperative bathing, intraoperative skin antisepsis, and antibiotic delivery. Within 6 months, the network achieved 96.7% reliability among institutions reporting adherence data. A 21% reduction in SSI rate was reported across network hospitals, from a mean baseline rate of 2.5 SSIs per 100 procedures to a mean rate of 1.8 SSIs per 100 procedures. The reduced rate was sustained for 15 months. CONCLUSIONS: Adoption of a SSI prevention bundle with concomitant reliability measurement reduced the network SSI rate. Linking reliability measurement to standardization at an institutional level may lead to safer care.