Pediatric nurses' fatigue descriptions in occupational injury reports: A descriptive qualitative study1.

Background: Despite the high risks associated with occupational fatigue in healthcare, few organizations require nurses to screen and report fatigue symptoms. As a result, little is known about if and how nurses would report fatigue while on the job. Objective: To determine if hospital-based pediatric nurses reported fatigue as part of an active injury reporting method. Methods: This secondary analysis of qualitative data used a descriptive design with content analysis. Data from the parent study were collected at a U.S. pediatric hospital where nurses verbally reported on-shift injuries or near misses and pre- and post-shift health status via a digital voice recorder. Researchers used content analysis to independently code data for nurses' references to fatigue. Codes were then analyzed for patterns and themes. Results: Approximately 30% (n = 104) of participants reported fatigue-related content. Emergent themes were Work Stressors, Individual Risk Factors, Fatigue Descriptors, Adverse Outcomes from Fatigue, Fatigue Buffers, Descriptors for Buffered Fatigue, and Favorable Outcomes from Buffered Fatigue. Fatigue descriptions align with prior literature, demonstrating the accuracy of the voice recorder data collection method. In addition, nurses expressed uncertainty about the appropriateness of reporting fatigue symptoms. Conclusion: Findings from this study support pediatric nurses will report fatigue, when provided an opportunity. Additional efforts are needed to better understand effective ways to improve fatigue reporting among nurses, including harnessing current technology for real-time reporting and how to change the culture around fatigue reporting.

Prospective Study of the Multisite Spread of a Medication Safety Intervention: Factors Common to Hospitals With Improved Outcomes.

Context and implementation approaches can impede the spread of patient safety interventions. The objective of this article is to characterize factors associated with improved outcomes among 9 hospitals implementing a medication safety intervention. Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) is a pharmacist-driven intervention that led to a sustained reduction in nephrotoxic medication-associated acute kidney injury (NTMx-AKI) at 1 hospital. Using qualitative comparative analysis, the team prospectively assessed the association between context and implementation factors and NTMx-AKI reduction during NINJA spread to 9 hospitals. Five hospitals reduced NTMx-AKI. These 5 had either (1) a pharmacist champion and >2 pharmacists working on NINJA (Scon 1.0, Scov 0.8) or (2) a nephrologist-implementing NINJA with minimal competing organizational priorities (Scon 1.0, Scov 0.2). Interviews identified ways NINJA team leaders obtained pharmacist support or successfully implemented without that support. In conclusion, these findings have implications for future spread of NINJA and suggest an approach to study spread of safety interventions more broadly.

Implementation of a Children's Hospital Acute Care Behavior Response Team.

BACKGROUND: Pediatric patients with behavioral needs are frequently admitted to the hospital for medical care; when behavioral crises occur, patients and staff are at risk for injury. Our aim was to implement a behavior response team (BRT) to increase the days between employee injury due to aggressive patient interactions on the inpatient medical units from 99 to 150 over 1 year. METHODS: A multidisciplinary team used quality improvement methods to design and implement the BRT system that includes 2 options: huddle to proactively plan for patients exhibiting early signs of escalation and STAT for immediate help for patients with imminent risk of harm to self or others. Using run and statistical process control charts, we tracked events per month, days between Occupational Safety & Health Administration-recordable events, and violent restraint use over time for 1 year after implementation. Staff pre and postimplementation surveys were compared to assess staff perception of safety and support provided by the BRT intervention. RESULTS: The BRT was implemented across the inpatient system in July 2020, with an average number of 13 events per month. Days between Occupational Safety & Health Administration-recordable events remained stable with a maximum of 134 days. Restraint use remained stable at 0.74 per 1000 patient days. The perception of behavioral support available to staff increased significantly pre to postsurvey. CONCLUSIONS: The implementation of a BRT can improve staff perception of support and confidence in safely caring for patients with behavior needs on the inpatient medical unit, although additional provider- and system-level improvements are needed to prevent employee injuries.

Gender and intention to leave healthcare during the COVID-19 pandemic among U.S. healthcare workers: A cross sectional analysis of the HERO registry.

IMPORTANCE: The COVID-19 pandemic stressed the healthcare field, resulting in a worker exodus at the onset and throughout the pandemic and straining healthcare systems. Female healthcare workers face unique challenges that may impact job satisfaction and retention. It is important to understand factors related to healthcare workers' intent to leave their current field. OBJECTIVE: To test the hypothesis that female healthcare workers were more likely than male counterparts to report intention to leave. DESIGN: Observational study of healthcare workers enrolled in the Healthcare Worker Exposure Response and Outcomes (HERO) registry. After baseline enrollment, two HERO 'hot topic' survey waves, in May 2021 and December 2021, ascertained intent to leave. Unique participants were included if they responded to at least one of these survey waves. SETTING: HERO registry, a large national registry that captures healthcare worker and community member experiences during the COVID-19 pandemic. PARTICIPANTS: Registry participants self-enrolled online and represent a convenience sample predominantly composed of adult healthcare workers. EXPOSURE(S): Self-reported gender (male, female). MAIN OUTCOME: Primary outcome was intention to leave (ITL), defined as having already left, actively making plans, or considering leaving healthcare or changing current healthcare field but with no active plans. Multivariable logistic regression models were performed to examine the odds of intention to leave with adjustment for key covariates. RESULTS: Among 4165 responses to either May or December surveys, female gender was associated with increased odds of ITL (42.2% males versus 51.4% females reported intent to leave; aOR 1.36 [1.13, 1.63]). Nurses had 74% higher odds of ITL compared to most other health professionals. Among those who expressed ITL, three quarters reported job-related burnout as a contributor, and one third reported experience of moral injury. CONCLUSIONS AND RELEVANCE: Female healthcare workers had higher odds of intent to leave their healthcare field than males. Additional research is needed to examine the role of family-related stressors. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT04342806.

Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: A multisite longitudinal assessment.

BACKGROUND: There is little longitudinal information about the type and frequency of harm resulting from medication errors among outpatient children with cancer. We aimed to characterize rates and types of medication errors and harm to outpatient children with leukemia and lymphoma over 7 months of treatment. METHODS: We recruited children taking medications at home for leukemia or lymphoma from three pediatric cancer centers. Errors were identified by chart review, in-home medication review, observation of administration, and interviews. Physician reviewers confirmed error (Fleiss' κ = 0.95), harm (Fleiss' κ = 0.82), and suggested interventions. Generalized linear mixed models with random effects were used to account for clustering by site. RESULTS: Among 131 children taking 1669 medications with 367 home visits, 408 errors were identified, including 242 with potential for harm and 39 with harm (1.0 harm per 1000 patient-days [95% CI, 0.1-9.8]). Ten percent of children were injured by errors and 42% had errors with potential for harm. Twenty-six percent of caregivers reported that miscommunication led to missed doses or overdoses at home. Children on >13 medications had significantly more serious medication errors than those on fewer medications (77% vs 61%; p = .05). Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%). CONCLUSIONS: In this longitudinal study, 10% children with leukemia or lymphoma experienced adverse drug events because of outpatient medication errors. Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering. PLAIN LANGUAGE SUMMARY: In this longitudinal study, medication errors in the clinic, pharmacy, or at home among children with leukemia or lymphoma over a 7-month period were common, and 10% suffered harm because of errors. Children on >13 medications had significantly more serious medication errors than those on fewer medications (77% vs 61%; p = .05). Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%). Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering.

Pilot trial of iBDecide: Evaluating an online tool to facilitate shared decision making for adolescents and young adults with ulcerative colitis.

INTRODUCTION: This pilot, randomized controlled trial aimed to evaluate the usability, among adolescents and young adults (AYAs) with ulcerative colitis (UC), of a web-based tool ('iBDecide') designed to facilitate shared decision making (SDM). METHODS: AYAs with UC (n = 35) were randomized to intervention (iBDecide, n = 14) and control (n = 12) arms before a scheduled clinic visit. We measured the usability of iBDecide, SDM, preferred decision-making style, decision conflict and intervention use. RESULTS: Participants in the intervention group found iBDecide easy to use and agreed that it made them feel ready to participate in decision making and that they would use it to prepare for appointments. There were 130 visits to iBDecide, lasting on average 3 min, 41 s. The medication and nutrition trackers were among the most-viewed pages. Pages specifically designed to facilitate SDM were viewed only four times. Across groups, too few participants reported making decisions during clinic visits for decision-related measures to be reported. CONCLUSIONS: This pilot trial provides evidence for the usability of iBDecide and guidance for developing a larger-scale trial of a combined web-based and in-clinic SDM intervention. Overall, iBDecide shows promise in engaging AYAs with UC in SDM and condition management. PATIENT OR PUBLIC CONTRIBUTION: Patients, specifically AYAs with UC, and healthcare providers were involved in the design of this study's intervention, iBDecide. Additionally, the research team, from study conception to manuscript writing, included a young adult with inflammatory bowel disease. CLINICAL TRIAL REGISTRATION: This study was registered at clinicaltrials.gov (NCT04207008).

Promoting Healthcare Worker Sleep: The Time Is Now.

Sufficient sleep is vital to the health and safety of healthcare workers and patients alike. Despite this, formal sleep promotion programs rarely exist within healthcare. Guidance does exist for how to incorporate strategies within healthcare organizations. Nurse leaders can spearhead efforts by promoting healthy sleep and instituting change through scheduling practices, unit policies, and supporting staff when barriers to healthy sleep develop.

Impact of the Early Phase of the COVID-19 Pandemic on US Healthcare Workers: Results from the HERO Registry.

BACKGROUND: The HERO registry was established to support research on the impact of the COVID-19 pandemic on US healthcare workers. OBJECTIVE: Describe the COVID-19 pandemic experiences of and effects on individuals participating in the HERO registry. DESIGN: Cross-sectional, self-administered registry enrollment survey conducted from April 10 to July 31, 2020. SETTING: Participants worked in hospitals (74.4%), outpatient clinics (7.4%), and other settings (18.2%) located throughout the nation. PARTICIPANTS: A total of 14,600 healthcare workers. MAIN MEASURES: COVID-19 exposure, viral and antibody testing, diagnosis of COVID-19, job burnout, and physical and emotional distress. KEY RESULTS: Mean age was 42.0 years, 76.4% were female, 78.9% were White, 33.2% were nurses, 18.4% were physicians, and 30.3% worked in settings at high risk for COVID-19 exposure (e.g., ICUs, EDs, COVID-19 units). Overall, 43.7% reported a COVID-19 exposure and 91.3% were exposed at work. Just 3.8% in both high- and low-risk settings experienced COVID-19 illness. In regression analyses controlling for demographics, professional role, and work setting, the risk of COVID-19 illness was higher for Black/African-Americans (aOR 2.32, 99% CI 1.45, 3.70, p < 0.01) and Hispanic/Latinos (aOR 2.19, 99% CI 1.55, 3.08, p < 0.01) compared with Whites. Overall, 41% responded that they were experiencing job burnout. Responding about the day before they completed the survey, 53% of participants reported feeling tired a lot of the day, 51% stress, 41% trouble sleeping, 38% worry, 21% sadness, 19% physical pain, and 15% anger. On average, healthcare workers reported experiencing 2.4 of these 7 distress feelings a lot of the day. CONCLUSIONS: Healthcare workers are at high risk for COVID-19 exposure, but rates of COVID-19 illness were low. The greater risk of COVID-19 infection among race/ethnicity minorities reported in the general population is also seen in healthcare workers. The HERO registry will continue to monitor changes in healthcare worker well-being during the pandemic. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT04342806.

The psychosocial work environment, musculoskeletal disorders and their functional consequences among pediatric healthcare providers.

OBJECTIVE: The goal of this study was to examine the association between aspects of the psychosocial work environment and prevalence of musculoskeletal disorders (MSDs) and associated functional consequences among pediatric healthcare providers. BACKGROUND: The psychosocial work demands make pediatric care providers susceptible to MSDs and subsequent functional consequences, but research on this at-risk group is lacking. METHODS: Randomly selected pediatric registered nurses, behavioral health specialists, and patient care assistants (N = 569) completed a survey assessing psychosocial factors, MSDs, and functional consequences (e.g., missing work). Logistic regression was used to assess associations between psychosocial factors and outcomes. RESULTS: The analysis yielded moderate-to-strong, significant associations between psychosocial environment factors and MSDs and their functional consequences. The odds of MSDs increased nearly three-fold in the highest quartile of the psychosocial summary score vs. the lowest (OR: 2.7, 95% CI: 1.6-4.5). The highest quartiles of the psychosocial environment measures were significantly associated with functional consequences of MSDs. CONCLUSION: Results confirm knowledge about the association between the psychosocial environment and MSDs and demonstrates the association also exists among pediatric providers. Our study highlights the importance of studying the functional consequences of MSDs, which characterize the impact of MSD burden at work and elsewhere.

The Gray Zone: Adolescent and Young Adult Decision Support Needs for Ulcerative Colitis.

Purpose. To understand the medical decision support needs specific to adolescents and young adults (AYAs) with ulcerative colitis (UC) and inform development of a decision support tool addressing AYAs' preferences. Methods. We conducted focus groups with AYAs with UC and mentors from a pediatric inflammatory bowel disease clinic's peer mentoring program. Focus groups were led by a single trained facilitator using a semistructured guide aimed at eliciting AYAs' roles in medical decision making and perceived decision support needs. All focus groups were audio recorded, transcribed, and coded by the research team. Data were analyzed using content analysis and the immersion crystallization method. Results. The facilitator led six focus groups: one group with peer mentors aged 18 to 24 years, three groups with patients aged 14 to 17 years, and two groups with patients aged 18 to 24 years. Decision timing and those involved in decision making were identified as interacting components of treatment decision making. Treatment decisions by AYAs were further based on timing, location (inpatient v. outpatient), and family preference for making decisions during or outside of clinic. AYAs involved parents and health care providers in medical decisions, with older participants describing themselves as "final decision makers." Knowledge and experience were facilitators identified to participating in medical decision making. Conclusions. AYAs with UC experience changes to their roles in medical decisions over time. The support needs identified will inform the development of strategies, such as decision support tools, to help AYAs with chronic conditions develop and use skills needed for participating in medical decision making.

Barriers and Facilitators of Adverse Event Reporting by Adolescent Patients and Their Families.

OBJECTIVES: The objectives were (1) to describe barriers and facilitators of adverse event reporting by adolescent patients and parents in a pediatric hospital and (2) to identify characteristics the participants wished to have in a formal reporting system of adverse events. METHODS: We used a qualitative design in which 6 focus groups, 3 with parents and 3 with adolescents, were conducted. The transcripts of audio recordings, notes of team debriefings, and written field notes of group behaviors were analyzed using NVivo software for qualitative data analysis. RESULTS: Participants reported that the quality of the experience with the health care system, type of communication with health care providers, and degree of personal self-confidence in communication within the health care system were 3 interacting factors influencing willingness to report adverse events. Preferred reporting mechanisms were different for different participants and included face-to-face meetings with hospital representatives, Web sites, smart phone capability, phone calls from a human, and paper mail. Reporting systems should be easy to use, ensure confidentiality, and provide user feedback. CONCLUSIONS: Experience, communication, and confidence are 3 factors that can engage an adolescent patient and parents in their health care. Confident adolescent patients and parents in turn have a possibility of reporting an adverse safety event given an opportunity.

Nurse Responses to Physiologic Monitor Alarms on a General Pediatric Unit.

BACKGROUND: Hospitalized children generate up to 152 alarms per patient per day outside of the intensive care unit. In that setting, as few as 1% of alarms are clinically important. How nurses make decisions about responding to alarms, given an alarm's low specificity for detecting clinical deterioration, remains unclear. OBJECTIVE: Our objective was to describe how bedside nurses think about and act upon monitor alarms for hospitalized children. DESIGN, SETTING, PARTICIPANTS: This was a qualitative study that involved the direct observation of nurses working on a general pediatric unit at a large children's hospital. MEASUREMENTS: We used a structured tool that included predetermined categories to assess nurse responses to monitor alarms. Data on alarm frequency and type were pulled from bedside monitors. RESULTS: We conducted 61.3 patient-hours of observation with nine nurses, in which we documented 207 nurse responses to patient alarms. For 67% of alarms heard outside of the room, the nurse decided not to respond without further assessment. Nurses most commonly cited reassuring clinical context (eg, medical team in room), as the rationale for alarm nonresponse. The nurse deemed clinical intervention necessary in only 14 (7%) of the observed responses. CONCLUSION: Nurses rely on clinical and contextual details to determine how to respond to alarms. Few of the alarm responses in our study resulted in a clinical intervention. These findings suggest that multiple system-level and educational interventions may be necessary to improve the efficacy and safety of continuous monitoring.

Enhancing the detection of injuries and near-misses among patient care staff in a large pediatric hospital.

Objectives Compared to other industries, healthcare has one of the highest rates of non-fatal occupational injury/illness. Evidence indicates these rates are underestimated, highlighting the need for improved injury surveillance. This study aims to demonstrate the feasibility of integrating active data collection in a passive injury surveillance system to improve detection of injuries in a healthcare establishment. Methods Using digital voice recorders (DVR), pediatric healthcare providers prospectively recorded events throughout their shift for two weeks. This sample-based active injury surveillance was then integrated into an institutional surveillance system (ISS) centered on passive data collection initiated by employee reports. Results Injuries reported using DVR during two-week intervals from February 2014 to July 2015 were 40.7 times more frequent than what would be expected on the basis of the usual ISS reports. Psychological injuries (eg, stress, conflict) and near-misses were captured at a rate of 16.1 per 1000 days [95% confidence interval (CI) 14.1-18.3] and 35.6 per 1000 days (95% CI 32.7-38.8), respectively. Finally, 68% (95% CI 65-72%) of participants preferred using DVR either as an alternative or complement to the existing ISS. Conclusions This study showed that it is feasible to improve injury surveillance in a healthcare establishment by integrating active data collection based on voice recording within a passive injury surveillance system. Enhanced surveillance provides richer information that can guide the development of effective injury prevention strategies.

Selection of employee personal protective equipment based on aggressive behavior in pediatric neuropsychiatry.

PURPOSE: Hospitalized patients with a developmental or intellectual disability and a psychiatric disorder (dual-diagnosis) often pose a risk to themselves or others leading to high injury rates for their providers. Therefore, evidence-based strategies to reduce employee injuries resulting from interactions are necessary. METHODS: To reduce injuries resulting from interactions with dual-diagnosis patients, the Initial Behavioural Assessment (IBA) and Protective Equipment Decision Key (PEDK) were used in inpatient neuropsychiatry. The IBA-PEDK identify patients' aggressive behaviors to provide employees with personal protective equipment (PPE). Inter-rater reliability, validity, and adherence were examined. RESULTS: Injuries significantly decreased after implementing the IBA-PEDK. The average kappa coefficient was 0.64 with a 90.6% agreement. Ninety-three percent of respondents reported wearing PPE at the time of injury. CONCLUSIONS: A quick, user-friendly tool that provides a standardized method for determining PPE based on patient-specific behavior can significantly reduce aggression-related injuries.

Developing a Patient Classification System for a Neonatal ICU.

OBJECTIVE: The purpose of this study was to develop a valid and reliable patient classification system (PCS) for a neonatal ICU (NICU). BACKGROUND: PCSs have been widely used to determine required care hours, budgeting, and staffing. There is a lack of and a vital need for a valid and reliable pediatric PCS because of differences in needs and treatment from adults. METHODS: Data were collected in a NICU using work sampling, chart reviews, and expert opinion. The resulting PCS was assessed for validity and reliability, ease of use, effectiveness, and satisfaction. RESULTS: The PCS showed significantly high reliability and validity. Survey scores revealed nurses perceived the tool to be easy to use and effective. CONCLUSIONS: Using subjective and objective methods, a NICU PCS was shown to be a valid and reliable measure to determine the hours per patient day required to provide care.

Noise Exposure on Pediatric Inpatient Units.

BACKGROUND: Noise is a problem placing registered nurses (RNs) at risk for safety events, decreased job performance, fatigue, irritability, and hearing loss. OBJECTIVE: The purpose of this study is to measure noise levels and sources on pediatric inpatient units as well as to explore the health impact of noise on RNs. METHODS: This was a descriptive nonexperimental study with 65 pediatric RNs from 14 units. Noise (levels, source, location, and activity), heart rate (HR), and stress were measured. Correlations between sound pressure levels (SPLs), HR, and stress were examined. RESULTS: Mean (SD) SPLs were 75.8 (8.9) dBA and were significantly higher than SPLs for patients. Noise was significantly associated with HR but not with time in tachycardia or stress. Primary sources of noise were employee conversations in patient rooms. CONCLUSIONS: On all units, SPLs exceeded protection agency guidelines. Cost-prohibitive structural changes underscore the importance of using behavioral and culture modification to reduce noise.

Errors and Nonadherence in Pediatric Oral Chemotherapy Use.

BACKGROUND: Nonadherence and medication error both limit the effectiveness of oral chemotherapy. The overlap between nonadherence and medication error is not well studied in children, and interventions strategies differ for each. Our objective was to describe nonadherence and errors in children with cancer to inform future interventions. METHODS: Nonadherence was measured using two self-report tools. Medication error was measured using medication review and observation of administration at home. Two clinicians made judgments about whether each error also represented an episode of nonadherence. RESULTS: Of 72 errors detected in 92 home visits, 27 were also instances of nonadherence. For example, parents gave a child 1 tablet of mercaptopurine every day rather than the prescribed 1 tablet 5 days a week and ½ tablet on weekends. Clinician reviewers judged that family interventions and health system interventions would be most effective in preventing the errors and nonadherence identified in this population of children with cancer. DISCUSSION: The relationship between medication errors and nonadherence is not well described in the literature. Our data indicate that medication error and nonadherence coexist in the same population and in the same patient. Interventions should address both to most effectively support self-management.

Impact of Noise on Nurses in Pediatric Intensive Care Units.

BACKGROUND: Excessive exposure to noise places nurses at risk for safety events, near-misses, decreased job performance, and fatigue. Noise is particularly a concern in pediatric intensive care units, where highly skilled providers and vulnerable patients require a quiet environment to promote healing. OBJECTIVE: To measure noise levels and noise duration on specialty pediatric intensive care units to explore sources of noise and its effects on the health of registered nurses. METHODS: In a cross-sectional pilot study, levels and sources of noise in 3 different specialty pediatric intensive care units were assessed. Fifteen nurses were observed for 4-hour sessions during a 24-hour period. Sound pressure levels (noise) and heart rate were measured continuously, and stress ratings were recorded. Descriptive statistics were calculated for noise (level, source, location, and activity), heart rate, and stress. The Pearson correlation coefficient was calculated to analyze the relationship between heart rate and noise. RESULTS: Mean noise level was 71.9 (SD, 9.2) dBA. Mean heart rate was 85.2/min (SD, 15.8/min) and was significantly associated with noise, unit, within-unit location, nurse sources, and noise activities. The most frequent sources of noise were patients' rooms, care activities, and staff communications. CONCLUSIONS: Noise levels in pediatric intensive care units exceed recommended thresholds and require immediate attention through effective interventions. Although noise was not associated with stress, a significant correlation with increased heart rate indicates that noise may be associated with adverse health outcomes.

Measurable results: Reducing staff injuries on a specialty psychiatric unit for patients with developmental disabilities.

BACKGROUND: Quality improvement initiative focused on staff injury reduction on a specialized inpatient psychiatric unit which offers acute stabilization for children and adolescents with complex high-risk behaviors. OBJECTIVE: To utilize quality improvement principles and interventions to reduce staff injuries on a specialized inpatient child/adolescent psychiatric unit. PARTICIPANTS: Direct care clinical staff within an inpatient psychiatric unit for patients with co-occurring developmental disabilities and psychiatric illness were the focus of the initiative. Direct care clinical staff and clinical administrators were the active participants in the quality improvement initiative, focusing upon the interactions between staff and patients. METHODS: OSHA-recordable injuries were documented to guide initiatives and measure outcomes on weekly run charts with raw data measures of all staff injuries and the number of days elapsed between injuries. Rapid Plan, Do, Study, Act (PDSA) cycles were utilized to test interventions and guide decision making. RESULTS: Three months of a structured and systematic intervention trial produced the first adopted interventions in August 2011. The following six months reflected a 65% reduction of staff injuries (from 2.2 injuries per week to 0.77 injuries per week). Between January and August 2011, there were eight OSHA-recordable injuries with an average of 26.5 days between injuries. The average number of days between OSHA-recordable injuries has increased from 26.5 days at baseline to 124 days. CONCLUSIONS: An initiative utilizing quality improvement principles reduced staff injuries on an inpatient specialized psychiatric unit. Reliability principles, system adaption, and engagement of the frontline nursing clinicians have proven to be foundational and vital to guide the initiative.

Inpatient falls in freestanding children's hospitals.

Patient falls are considered a significant safety risk, but little evidence regarding the significance of falls in children is available. A multisite, observational study of fall events occurring in pediatric inpatients (younger than 18 years of age) from Child Health Corporation of America member hospitals was conducted to determine the prevalence and significance of falls. Fall prevalence was 0.84 per 1,000 patient days with 48% classified as preventable. Injuries occurred in 32%, but only two falls resulted in an increased length of stay; none resulted in permanent disability or death. Only 47% of the children who fell were identified to be at risk for fall. Alert mechanisms were used in 60% and preventive measures in 23%. These findings suggest that while inpatient pediatric fall rates are lower than those of adults, greater diligence in identification and risk reduction may further reduce the prevalence of falls and the proportion of fall-related injuries.