Improving Safety Recommendations Before Implementation: A Simulation-Based Event Analysis to Optimize Interventions Designed to Prevent Recurrence of Adverse Events.

INTRODUCTION: Pediatric inpatients are at high risk of adverse events (AE). Traditionally, root cause analysis was used to analyze AEs and identify recommendations for change. Simulation-based event analysis (SBEA) is a protocol that systematically reviews AEs by recreating them using in situ simulated patients, to understand clinician decision making, improve error discovery, and, through guided sequential debriefing, recommend interventions for error prevention. Studies suggest that these interventions are rarely tested before dissemination. This study investigates the use of simulation to optimize recommendations generated from SBEA before implementation. METHODS: Recommendations and interventions developed through SBEA of 2 hospital-based AEs (event A: error of commission; event B: error of detection) were tested using in situ simulation. Each scenario was repeated 8 times. Interventions were modified based on participant feedback until the error stopped occurring and data saturation was reached. RESULTS: Data saturation was reached after 6 simulations for both scenarios. For scenario A, a critical error was repeated during the first 2 scenarios using the initial interventions. After modifications, errors were corrected or mitigated in the remaining 6 scenarios. For scenario B, 1 intervention, the nursing checklist, had the highest impact, decreasing average time to error detection to 6 minutes. Based on feedback from participants, changes were made to all but one of the original proposed interventions. CONCLUSIONS: Even interventions developed through improved analysis techniques, like SBEA, require testing and modification. Simulation optimizes interventions and provides opportunity to assess efficacy in real-life settings with clinicians before widespread implementation.

Simulation-Based Event Analysis Improves Error Discovery and Generates Improved Strategies for Error Prevention.

INTRODUCTION: An adverse event (AE) is a negative consequence of health care that results in unintended injury or illness. The study investigates whether simulation-based event analysis is different from traditional event analysis in uncovering root causes and generating recommendations when analyzing AEs in hospitalized children. METHODS: Two simulation scenarios were created based on real-life AEs identified through the hospital's Safety Reporting System. Scenario A involved an error of commission (inpatient drug error) and scenario B involved detecting an error that already occurred (drug infusion error). Each scenario was repeated 5 times with different, voluntary clinicians. Content analysis, using deductive and inductive approaches to coding, was used to analyze debriefing data. Causes and recommendations were compiled and compared with the traditional event analysis. RESULTS: Errors were reproduced in 60% (3/5) of scenario A. In scenario B, participants identified the error in 100% (5/5) of simulations (average time to error detection = 15 minutes). Debriefings identified reasons for errors including product labeling, memory aid interpretation, and lack of standard work for patient handover. To prevent error, participants suggested improved drug labeling, specialized drug kits, alert signs, and handoff checklists. Compared with traditional event analysis, simulation-based event analysis revealed unique causes for error and new recommendations. CONCLUSIONS: Using simulation to analyze AEs increased unique error discovery and generated new recommendations. This method is different from traditional event analysis because of the immediate clinician debriefings in the clinical environment. Hospitals should consider simulation-based event analysis as an important addition to the traditional process.

Development and pilot of an interprofessional pediatric resuscitation program for non-acute care inpatient providers.

Multiprofessional ward healthcare providers are generally unprepared to assemble and engage in the initial resuscitation of pediatric inpatients. This is important as the performance of these first-responders, in the several minutes prior to the arrival of acute care support, may have significant effects on overall patient outcome. Accordingly, we aimed to develop and pilot a training program intended for non-acute care inpatient providers, relevant to their working context. Using the latest theory and evidence in medical education, we created an interprofessional, entirely in-situ, simulation-based small-group activity. The activity was then piloted for four months with the goals of assessing perceived usefulness, as well as implementation factors such as participant accessibility and overall resource requirements. A total of 37 interprofessional (physician and nursing) staff were trained in 16 small group sessions over four months. Post-participation questionnaires revealed that the activity was perceived to be highly useful for their practice; especially the rapid cycle deliberate practice instructional method, and the increased focus on crisis resource management. Resource requirements were comparable to, and perhaps less than, existing acute care training programs. This project describes the preliminary steps taken in creating a curriculum intended to improve interprofessional resuscitation performance across an institution.

Increased Mortality and Length of Stay Associated With Medical Emergency Team Review in Hospitalized Pediatric Patients: A Retrospective Cohort Study.

OBJECTIVE: Rapid response systems using medical emergency teams reduce hospital wide cardiorespiratory arrest and mortality. While rapid response systems improve hospital-wide outcomes, children receiving medical emergency team review may still be at increased risk for morbidity and mortality. The study purpose was to compare the length of stay and mortality rate in children receiving a medical emergency team review with those of other hospitalized children. DESIGN: Retrospective cohort study. SETTING: Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. PATIENTS: Cohort of 42,308 pediatric admissions to the general inpatient ward. INTERVENTIONS: Data over 7 years were obtained from a prospectively maintained rapid response systems database. MEASUREMENTS AND MAIN RESULTS: From the cohort, 995 (2.35%) of the admissions had one and 276 (0.65%) had multiple medical emergency team activations. When compared with patients without, children having one or multiple medical emergency team reviews had 13.34 (95% CI, 5.33-33.2) and 50.10 (95% CI, 19.86-126.39) times the odds of death, respectively. Patients experiencing a medical emergency team review stayed in hospital 1.59 times (95% CI, 1.39-1.82) longer, whereas those with multiple medical emergency team reviews stayed 2.44 times (95% CI, 1.85-3.20) longer. The associations remained significant after controlling for important confounders and excluding elective admissions from the analyses. Most repeat medical emergency team reviews occurred within a day of the initial review or involved patients with multiple comorbidities. CONCLUSIONS: Our study suggests that pediatric patients reviewed by the medical emergency team are at significantly higher risk of mortality and longer length of stay than general ward inpatients. As well, patients with multiple medical emergency team reviews were at particularly high risk compared with patients with one medical emergency team review. Patients who experience medical emergency team reviews should be recognized as a high-risk group, and future studies should consider how to decrease morbidity and mortality. Based on our findings, we suggest that these patients be followed for 24-48 hours after any medical emergency team activation.

Improved Clinical Performance and Teamwork of Pediatric Interprofessional Resuscitation Teams With a Simulation-Based Educational Intervention.

OBJECTIVES: To measure the effect of a 1-day team training course for pediatric interprofessional resuscitation team members on adherence to Pediatric Advanced Life Support guidelines, team efficiency, and teamwork in a simulated clinical environment. DESIGN: Multicenter prospective interventional study. SETTING: Four tertiary-care children's hospitals in Canada from June 2011 to January 2015. SUBJECTS: Interprofessional pediatric resuscitation teams including resident physicians, ICU nurse practitioners, registered nurses, and registered respiratory therapists (n = 300; 51 teams). INTERVENTIONS: A 1-day simulation-based team training course was delivered, involving an interactive lecture, group discussions, and four simulated resuscitation scenarios, each followed by a debriefing. The first scenario of the day (PRE) was conducted prior to any team training. The final scenario of the day (POST) was the same scenario, with a slightly modified patient history. All scenarios included standardized distractors designed to elicit and challenge specific teamwork behaviors. MEASUREMENTS AND MAIN RESULTS: Primary outcome measure was change (before and after training) in adherence to Pediatric Advanced Life Support guidelines, as measured by the Clinical Performance Tool. Secondary outcome measures were as follows: 1) change in times to initiation of chest compressions and defibrillation and 2) teamwork performance, as measured by the Clinical Teamwork Scale. Correlation between Clinical Performance Tool and Clinical Teamwork Scale scores was also analyzed. Teams significantly improved Clinical Performance Tool scores (67.3-79.6%; p < 0.0001), time to initiation of chest compressions (60.8-27.1 s; p < 0.0001), time to defibrillation (164.8-122.0 s; p < 0.0001), and Clinical Teamwork Scale scores (56.0-71.8%; p < 0.0001). A positive correlation was found between Clinical Performance Tool and Clinical Teamwork Scale (R = 0.281; p < 0.0001). CONCLUSIONS: Participation in a simulation-based team training educational intervention significantly improved surrogate measures of clinical performance, time to initiation of key clinical tasks, and teamwork during simulated pediatric resuscitation. A positive correlation between clinical and teamwork performance suggests that effective teamwork improves clinical performance of resuscitation teams.

Routine Medical Emergency Team Assessments of Patients Discharged From the PICU: Description of a Medical Emergency Team Follow-Up Program.

OBJECTIVE: This study describes one follow-up program in the Ontario Rapid-Response System project consisting of routine medical emergency team visits of patients discharged from the PICU consisting of two planned visits within 48 hours following discharge. Study purpose was to describe interventions provided and the patient characteristics associated with medical emergency team utilization. DESIGN: Retrospective cohort study. SETTING: Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. PATIENTS: Discharged pediatric patients from PICU. INTERVENTIONS: Data over 41 months were obtained from a prospectively maintained rapid-response system database. Major medical emergency team support was defined as an early unplanned visit, intervention, or readmission during the follow-up period. MEASUREMENTS AND MAIN RESULTS: Interrupted time-series analysis comparing the 2 years preceding rapid-response system implementation with the subsequent 4 years demonstrated a statistically significant immediate change in PICU readmission rate (-5.5%, p = 0.0001). There were 1,805 patients followed after PICU discharge. During the 48-hour planned follow-up period, 4% of patients received an unplanned medical emergency team visit and 13% received an active intervention. Analysis of the first medical emergency team visit identified that 10% received major medical emergency team support. After the initial visit, 6% of patients received major medical emergency team support with predictive characteristics being an unplanned first visit (odds ratio, 3.7; 95% CI, 1.6-8.5) or an intervention during the first visit (odds ratio, 3.5; 95% CI, 2.1-5.8). Multiple diseased organs were associated with major medical emergency team support after the initial visit for recent surgical patients (odds ratio, 3.0 vs 1.2; p = 0.03). CONCLUSIONS: Routine medical emergency team visits following PICU discharge reduced the risk of early readmission. Our results suggest that one in seven patients in the follow-up program receive major medical emergency team support. We suggest a follow-up program with at least one routine medical emergency team visit within the first 24 hours of discharge with a second planned visit reserved for complex postsurgical patients.