A Quality Education: A Comprehensive Review of a Combined Longitudinal and Specialty Track Quality Improvement and Patient Safety Medical School Curriculum.

Structured quality improvement and patient safety (QI/PS) education has increased at every level of medical education; however, great variability exists in the content taught. Here, the authors present a longitudinal model for medical student QI/PS education that is currently implemented at the University of Florida College of Medicine. The curriculum is taught with a variety of teaching methods incorporated into each year with increasing levels of clinical implementation. This curriculum is multimodal and introduces students to QI/PS concepts, presents mock scenarios, and eventually encourages clinical application to situations students experience during their own clinical practice. Additionally, a specialized track for students to have further immersion into this field of medicine is described, which involves specialized training, expanded educational opportunities, and a capstone project. Both the curriculum and specialized track contain explicit clinical integration to ensure students are prepared to enter the medical profession to engage in QI/PS endeavors.

Transforming the Culture of Peer Review: Implementation Across Three Departments in an Academic Health Center.

OBJECTIVES: Although many health care institutions believe that clinical peer review is vital for identifying and improving quality of care, peer review is perceived by many clinicians as variable and inherently punitive. Successful peer review requires institutional leadership and adoption of a just culture approach to investigating and determining accountability for medical errors that result in harm. METHODS: We describe how an academic medical center implemented and adapted its clinical peer review processes to be consistent with just culture theory and provide a roadmap that other institutions may follow. Specific examples of peer review are highlighted to show how the process improved patient safety in the departments of emergency medicine, internal medicine, and pediatrics. RESULTS: The most significant process improvement was shifting from a tradition of assigning letter grades of "A," "B," or "C" to determine whether preventable adverse events were caused by "human error," "at-risk behavior," or "reckless behavior." This categorization of human behaviors enabled patient safety officers within 3 departments to develop specific interventions to protect patients and enlist physician support for improving clinical systems. CONCLUSIONS: Each department's success was due to recognition of different patient and provider cultures that offer unique challenges. The transformation of peer review was a crucial first step to shift perceptions of peer review from a punitive to a constructive process intended to improve patient safety. Our experience with reengineering clinical peer review shows the importance of focusing on just culture as a key method to prevent patient harm.

Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value.

OBJECTIVES: The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children. METHODS: A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations. RESULTS: Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis. CONCLUSIONS: We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.

Preventive oral health care in early childhood: knowledge, confidence, and practices of pediatricians and family physicians in Florida.

OBJECTIVE: To examine the relationships among pediatricians' and family physicians' oral health training, knowledge, confidence, and practice patterns. STUDY DESIGN: A survey of physicians identified through the membership databases of the Florida Academy of Family Physicians and the Florida Pediatric Society was conducted in 2008. Responses of pediatricians and family physicians were compared through bivariate and multivariate analyses. RESULTS: Although training was not directly associated with performing recommended practices, there were positive associations between training and confidence and between confidence and performing recommended practices (P <.05). Pediatricians were more likely than family physicians to answer fluoride-related knowledge questions correctly and reported greater confidence (P <.05). Less than 20% of the respondents reported counseling parents about bringing their child to the dentist before age 1 year or inquiring about the parents' dental health. CONCLUSIONS: Oral health training appears to promote confidence in performing recommended oral health practices. Differences in fluoride knowledge by provider type suggest that fluoride guidance has been disseminated more effectively among pediatricians than among family physicians. Educational content of oral health training programs should place increased emphasis on current fluoride guidance, early dental visits, and assessing parents' oral health. Instructional methods should address physicians' confidence, particularly among family physicians.

Hypercalcemia from hypervitaminosis A in a child with autism.

Objectives Vitamin A is essential for normal cellular physiology and is often taken as a dietary supplement. Hypervitaminosis A can lead to hypercalcemia by increasing osteoclasts and subsequent bone resporption. Dietary supplements including vitamin A are new popular treatment stategies for autism. Case presentation We report a five-year old boy with autism spectrum disorder presenting with severe abdominal pain and bilateral lower extremity pain, who was found to have persistent hypercalcemia due to hypervitaminosis A. The patient ingested over 700 times the recommended intake of Vitamin A per day for age. Retention of vitamin A in the liver and adipose tissue causes toxic levels of retinoids and hypercalcemia. Conclusions Acute treatment included intravenous rehydration, furosemide, and calcitonin. Pamidronate was the definitive treatment for hypercalcemia from hypervitaminosis A due to its osteoclast inhibition and long biologic half-life. Parents should be counseled on risks of toxicity and absence of evidence showing benefits of vitamin A therapy for autism.

A patient with an unusual cause right lower quadrant pain and vomiting: pyelonephritis of an ectopic right kidney masquerading as acute appendicitis.

An adolescent female presented with one day of abdominal pain and clinical findings of acute appendicitis. CT scan revealed an ectopic right kidney with changes of acute pyelonephritis. This paper underscores the importance of imaging the right pelvis prior to surgical intervention in suspected cases of acute appendicitis in children.