A Quality Initiative to Improve Appropriate Medication Dosing in Pediatric Patients with Obesity.

Introduction: Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year. Methods: The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department. Results: Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months. Conclusions: Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.

Developing Tools to Enhance the Adaptive Capacity (Safety II) of Health Care Providers at a Children's Hospital.

Current safety efforts in health care use Safety I (find and fix), which has benefits and shortcomings. Safety leaders in multiple industries realize that complex adaptive systems require a new approach-Safety II (proactive safety). Our goal was to develop practical, usable tools to spread Safety II and resilience engineering competencies to clinical frontline staff. Using our prior research and Plan-Do-Study-Act cycles, we developed tools to enhance Safety II competencies that individuals with various backgrounds could understand. Tools address recognizing (Pause to Predict), responding (IDEA), and learning (Feed Forward). These are being taught organizationally in a unit-by-unit sequence. Use of these tools is expected to prompt a shift toward a more proactive mental model of safety that we want our frontline providers to adopt. Coordinating the expertise of bedside clinicians during unprecedented events can safely expand the boundaries of conditions under which we can provide high-quality care by increasing individuals' and subsequently our systems' adaptive capacity. We believe this is the first work describing attempts to operationalize Safety II concepts broadly in a health care organization.

Validation of the Second Victim Experience and Support Tool-Revised in the Neonatal Intensive Care Unit.

OBJECTIVE: The aim of the study was to validate a revised version of the Second Victim Experience and Support Tool (SVEST-R). The SVEST survey instrument was developed to measure the emotional and professional impact of medical errors and adverse patient events on healthcare providers and can help healthcare organizations evaluate the effectiveness of support resources. METHODS: An SVEST-R was completed by 316 healthcare providers from seven neonatal intensive care units affiliated with a large, pediatric hospital. The original 29-item measure was expanded to 43 items to assess eight psychosocial domains (psychological distress, physical distress, colleague support, supervisor support, institutional support, nonwork-related support, professional self-efficacy, resilience) and two employment-related domains (turnover intentions, absenteeism) associated with the second victim experience. Seven additional items assessed desired forms of support (e.g., time away from the unit). A confirmatory factor analysis evaluated the factor structure of the modified measure. RESULTS: The initial confirmatory factor analysis did not reveal an acceptable factor structure; thus, eight items were removed because of inadequate factor loadings or for conceptual reasons. This resulted in an acceptable model for the final 35-item measure. The final version included nine factors (i.e., psychological distress, physical distress, colleague support, supervisor support, institutional support, professional self-efficacy, resilience, turnover intentions, and absenteeism), with Cronbach α ranging from 0.66 to 0.86. CONCLUSIONS: The SVEST-R is a valid measure for assessing the impact of errors or adverse events on healthcare providers. Importantly, the SVEST-R now includes positive outcomes (i.e., resilience) that may result from the second victim experience.

Evaluation of medication safety resources in pediatric hospitals.

PURPOSE: As health systems continue to expand pharmacy and clinical services, the ability to evaluate potential medication safety risks and mitigate errors remains a high priority. Workload and productivity monitoring tools for the assessment of operational and clinical pharmacy services exist. However, such tools are not currently available to justify medication safety pharmacy services. The purpose of this study is to determine methods used to assess, allocate, and justify medication safety resources in pediatric hospitals. METHODS: A 32-question survey was designed and distributed utilizing the Research Electronic Data Capture (REDCap) tool. The survey was disseminated to 46 pediatric hospitals affiliated with the Children's Hospital Association (CHA). The survey was distributed in October 2018, and the respondents were given 3 weeks to submit responses. Data analysis includes the use of descriptive statistics. Categorical variables were summarized by frequencies and percentages to distinguish the differences between pediatric health systems. RESULTS: Of 26 respondents, 15.4% utilized metrics to justify medication safety resources. Metrics utilized were based on medication dispenses, projects, and error coding. Twenty-three percent of respondents were dissatisfied with current pharmacy-based medication safety resources within the organization. There was variability of medication safety resources within pediatric hospitals, including the number of dedicated full-time equivalents, time spent on tasks, and task prioritization. CONCLUSION: Assessing medication safety resources at various pediatric hospitals highlights several potential barriers and opportunities. This information will serve as the foundation for the creation of a standardized workload assessment tool to assist pharmacy leaders with additional resource justification.

Clinical Decision Support to Improve Dosing Weight Use in Infants with Neonatal Abstinence Syndrome.

INTRODUCTION: Opioid abuse in the United States is a public health emergency. From 2000 to 2009, prenatal maternal opiate use increased from 1.19 to 5.63 per 1,000 births, with up to 80% of in utero opioid-exposed infants requiring pharmacotherapy. This study aimed to increase the percentage of neonatal abstinence syndrome (NAS) medication orders based on birth weight (BW) in neonates admitted to a neonatal intensive care unit with a principal diagnosis of NAS from 29% to 90%, within 4 months of project initiation, and to sustain this for 6 months. METHODS: This project occurred at an academic medical center with 5,000 deliveries per year and a 49-bed Level III neonatal intensive care unit. We used the Institute for Healthcare Improvement methodology, largely focusing interventions on clinical decision support (CDS) tools. We plotted all measures on Shewhart charts, and Nelson rules differentiated special versus common cause variation. RESULTS: The percent of orders based on BW increased from 29% to 78% after implementing multiple interventions focused primarily on CDS. However, this later decreased to 48% as workarounds began. There was also a significant decrease in the length of stay variability, which persisted throughout the project. DISCUSSION: CDS is a helpful tool to guide prescribing behavior; however, workarounds can negate its usefulness. Standardized use of BW for weight-based NAS medication prescribing can decrease the length of stay variability. Further studies are needed using a human factors approach to minimize workarounds in CDS and potentially decrease the length of stay in neonates with NAS.

Safety II Behavior in a Pediatric Intensive Care Unit.

: media-1vid110.1542/5763093009001PEDS-VA_2018-0018Video Abstract BACKGROUND AND OBJECTIVE: Safety I error elimination concepts are focused on retrospectively investigating what went wrong and redesigning system processes and individual behaviors to prevent similar future occurrences. The Safety II approach recognizes complex systems and unpredictable circumstances, mandating flexibility and resilience within systems and among individuals to avoid errors. We hypothesized that in our high-complexity and high-risk PICU, Safety II concepts contribute to its remarkably low adverse drug event rate. Our goal was to identify how this microsystem enacts Safety II. METHODS: We conducted multidisciplinary focus group sessions with PICU members using nonleading, open-ended questions to elicit free-form conversation regarding how safety occurs in their unit. Qualitatively analyzing transcripts identified system characteristics and behaviors potentially contributing to low adverse drug event rates in PICU. Researchers skilled in qualitative methodologies coded transcripts to identify key domains and common themes. RESULTS: Four domains were identified: (1) individual characteristics, (2) relationships and interactions, (3) structural and environmental characteristics, and (4) innovation approaches. The themes identified in the first 3 domains are typically associated with Safety I and adapted for Safety II. Themes in the last domain (innovation approaches) were specific to Safety II, which were layered on Safety I to improve results under unusual situations. CONCLUSIONS: Safety II behavior in this unit was based on strong Safety I behaviors adapted to the Safety II environment plus innovation behaviors specific to Safety II situations. We believe these behaviors can be taught and learned. We intend to spread these concepts throughout the organization.

The emotional impact of errors or adverse events on healthcare providers in the NICU: The protective role of coworker support.

AIMS: To examine the impact of errors or adverse events on emotional distress and professional quality of life in healthcare providers in the neonatal intensive care unit, and the moderating role of coworker support. BACKGROUND: Errors or adverse events can result in negative outcomes for healthcare providers. However, the role of coworker support in improving emotional and professional outcomes has not been examined. DESIGN: A cross-sectional online survey from a quality improvement initiative to train peer supporters in a neonatal intensive care unit. METHODS: During 2015, 463 healthcare providers in a neonatal intensive care unit completed a survey assessing their experiences with an error or adverse event, anxiety, depression, professional quality of life and coworker support. RESULTS: Compared with those who did not experience an error or adverse event (58%), healthcare providers who observed (23%) or were involved (19%) in an incident reported higher levels of anxiety and secondary traumatic stress. Those who were involved in an event reported higher levels of depression and burnout. Differences between the three groups (no event, observation and involvement) for compassion satisfaction were non-significant. Perceived coworker support moderated the association between experiencing an event and both anxiety and depression. Specifically, experiencing an event was associated with higher levels of anxiety and depression when coworkers were perceived as low in supportiveness, but not when they were viewed as highly supportive. CONCLUSION: Findings suggest that errors or adverse events can have a harmful impact on healthcare providers and that coworker support may reduce emotional distress.

Impact of a pharmacy student-driven medication delivery service at hospital discharge.

PURPOSE: A pharmacy student-driven discharge service developed for patients to reduce the number of medication errors on after-visit summaries (AVSs) is discussed. METHODS: An audit of AVS documents was conducted before the implementation period (September 3 to October 23, 2013) to identify medication errors. As part of the audit, a pharmacist review of the discharge medication list was completed to determine the number and types of errors that occurred. A student-driven discharge service with AVS review was developed in collaboration with nursing and medical residents. Students reviewed a patient's AVS, delivered the discharge prescriptions to bedside, and conducted medication reconciliation with the patient and family. The AVS audit was conducted after implementation of these services to assess the impact on medication errors. RESULTS: It was observed that 72% (108 of 150) of AVSs contained at least 1 error before discharge and AVS review. During the 2-month postimplementation period (September 3 to October 23, 2014), this decreased to 27% (34 of 127), resulting in a 52% absolute reduction in the number of AVSs with at least 1 medication error (p < 0.0001). The most common error was as-needed medication with no indication, which decreased from 55% in the preimplementation audit to 16% in the postimplementation audit. Prescribing to Nationwide Children's Hospital's outpatient pharmacy increased from 57% in the preimplementation period to 73% in the postimplementation period for the general pediatrics service. CONCLUSION: A pharmacy student-driven discharge and medication delivery service reduced the number of AVSs and increased access to medications for patients.

Deployment of a Second Victim Peer Support Program: A Replication Study.

BACKGROUND: The second victim phenomenon occurs when health-care providers experience significant professional distress (compassion dissatisfaction, burnout, secondary traumatic stress) and psychological distress (shame, anxiety, and depression) as a result of medical errors or adverse patient outcomes. Few hospitals have institution-wide systems in place to assist employees through the recovery process. METHODS: At Nationwide Children's Hospital (NCH), a peer-based support program called "YOU Matter" was executed and spread hospital-wide. The program emulated the framework and execution strategy designed by University of Missouri Health Care's (MUHC) "forYOU" Team. Strategic elements of the program's structure were reviewed and adapted for NCH with system-wide deployment and enhancement to include electronic peer support reporting. This article summarizes program implementation, management, and sustainment over the past 2 years. RESULTS: By following University of Missouri Health Care's model, we successfully deployed an institution-wide second victim program. Since the November 2013 initiation, we have documented 232 peer and 21 group encounters. High-risk clinical areas for second victimization at NCH included the emergency department (ED), pediatric intensive care unit (PICU), cardiothoracic intensive care unit (CTICU), and pharmacy department. Registered nurses (RNs) and licensed practical nurses (LPNs) have had the highest number of encounters necessitating second victim support (32%). Supported staff reported improved emotional state and improved return-to-work metrics. CONCLUSIONS: An organization's culture of patient safety can be enhanced by ensuring staff psychological safety. Programs like "YOU Matter" and the "forYOU" Team are essential building blocks to improve the overall safety culture and quality of care. Implementation of "YOU Matter" at NCH validates the MUHC program and demonstrates its generalizability to other health-care institutions.

Reduction of immunization errors through practitioner education and addition of age-specific alerts in the electronic prescribing system.

PURPOSE: The reduction of immunization errors through the use of age-specific alerts within the electronic medical record (EMR) and mandatory interactive education for prescribers is described. METHODS: A health system-wide initiative was implemented at an academic pediatric hospital to reduce the number of immunization errors. The preimplementation period (January 1-December 31, 2013) involved a baseline review of adverse drug events (ADEs) reported through a voluntary event reporting system to determine the number and types of immunization errors. During the prescribing phase of the medication-use process, 57% (43 of 75) of errors occurred. First, age-based restrictions were implemented within the EMR. This was followed by mandatory immunization education for all prescribers working in the primary care network. Data collection included all reported vaccine errors within the voluntary event reporting system and completion rates of education by physicians, nurse practitioners, and medical residents. RESULTS: During the seven-month postimplementation period (January 1- July 31, 2014), prescribing events decreased from 57% to 25%. Following implementation of age-specific immunization alerts and mandatory prescriber education, the hospital went 175 days without a vaccine ADE. CONCLUSION: The implementation of age-specific alerts within the EMR and mandatory prescriber education decreased the number of immunization errors within a pediatric health system.

Implementation of a "second victim" program in a pediatric hospital.

PURPOSE: A formal support program for pharmacy employees involved in adverse drug events, patient-related injuries, and other traumatic work experiences is described. SUMMARY: Healthcare workers are sometimes referred to as the "second victims" of patient care mishaps due to the anxiety, loss of confidence, and career uncertainty they may experience. After a survey indicating that about 30% of its staff had been involved in a second-victim event, the Nationwide Children's Hospital (NCH) pharmacy department implemented a peer-based support initiative (the YOU Matter program) based on an established three-tiered intervention model. All staff members are trained to identify second victims. The core of the program is a team of trained peer supporters who serve as first responders; if additional support is required, referrals to behavioral health, social work, and employee assistance personnel are made as appropriate. Staff members involved in troubling work-related events can seek support via a Web-based portal for event reporting and discussion. Since the launch of the NCH second victim program, the team of trained peer supporters has been expanded from 13 to over 120. In a postimplementation survey, 85% of the NCH pharmacy department staff indicated that the YOU Matter program has been beneficial. CONCLUSION: The majority of the NCH pharmacy staff reported that the department benefited from implementation of the second victim program. A survey conducted five months after implementation of the program revealed that 3 respondents had personally used the program and 11 had referred a coworker to a peer supporter.

An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events.

OBJECTIVE: To reduce the rate of harmful adverse drug events (ADEs) of severity level D-I from a baseline peak of 0.24 ADE/1000 doses to 0.08 ADE/1000 doses. STUDY DESIGN: A hospital-wide, quasi-experimental time series quality improvement (QI) initiative to reduce ADEs was implemented. High-reliability concepts, microsystem-based multidisciplinary teams, and QI science methods were used. ADEs were detected through a combination of voluntary reporting, trigger tool analysis, reversal agent review, and pharmacy interventions. A multidisciplinary ADE Quality Collaborative focused on medication use processes, not on specific classes of medications. Effective interventions included huddles and an ADE prevention bundle. RESULTS: The rate of harmful ADEs initially increased by >65% because of increased error reporting, temporally associated with the implementation of a program focused on high reliability and an improved safety culture. The quarterly rate was 0.17 ADE/1000 dispensed doses in Q1 2010. By the end of Q2 2013, the rate had decreased by 76.5%, to 0.04 ADE/1000 dispensed doses (P < .001). CONCLUSION: Using an internal collaborative model and QI methodologies focused on medication use processes, harmful ADEs were reduced hospital-wide by 76.5%. The concurrent implementation of a high-reliability, safety-focused program was important as well.

Improvement of medication event interventions through use of an electronic database.

PURPOSE: Patient safety enhancements achieved through the use of an electronic Web-based system for responding to adverse drug events (ADEs) are described. SUMMARY: A two-phase initiative was carried out at an academic pediatric hospital to improve processes related to "medication event huddles" (interdisciplinary meetings focused on ADE interventions). Phase 1 of the initiative entailed a review of huddles and interventions over a 16-month baseline period during which multiple databases were used to manage the huddle process and staff interventions were assigned via manually generated e-mail reminders. Phase 1 data collection included ADE details (e.g., medications and staff involved, location and date of event) and the types and frequencies of interventions. Based on the phase 1 analysis, an electronic database was created to eliminate the use of multiple systems for huddle scheduling and documentation and to automatically generate e-mail reminders on assigned interventions. In phase 2 of the initiative, the impact of the database during a 5-month period was evaluated; the primary outcome was the percentage of interventions documented as completed after database implementation. During the postimplementation period, 44.7% of assigned interventions were completed, compared with a completion rate of 21% during the preimplementation period, and interventions documented as incomplete decreased from 77% to 43.7% (p < 0.0001). Process changes, education, and medication order improvements were the most frequently documented categories of interventions. CONCLUSION: Implementation of a user-friendly electronic database improved intervention completion and documentation after medication event huddles.