Serious Experience Events: Applying Patient Safety Concepts to Improve Patient Experience.

Pediatric healthcare systems have successfully decreased patient harm and improved patient safety by adopting standardized definitions, processes, and infrastructure for serious safety events (SSEs). We have adopted those patient safety concepts and used that infrastructure to identify and create action plans to mitigate events in which patient experience is severely compromised. We define those events as serious experience events (SEEs). The purpose of this research brief is to describe SEE definitions, infrastructure used to evaluate potential SEEs, and creation of action plans as well as share our preliminary experiences with the approach.

Healthcare Worker Serious Safety Events: Applying Concepts from Patient Safety to Improve Healthcare Worker Safety.

INTRODUCTION: Patient safety has improved pediatric healthcare by defining when patient safety events meet criteria as serious safety events (SSEs). Similar concepts apply to healthcare worker (HCW) safety. We describe the newly designed process for HCW injury reporting, the process for evaluating HCW SSEs, and early experience with the new systems. METHODS: The work to redesign our approach to HCW safety included 2 parts: (1) process flow mapping and redesigning the work for HCW injury reporting; and (2) creating a process to categorize HCW injuries and determine when such injuries rise to a HCW SSE level. We evaluated the mean time per month from HCW injury to reporting and compared those values during the postimplementation time. We also evaluated the team's experience with the first 4 potential HCW SSEs. RESULTS: By improving the process flow, the mean time to reporting decreased significantly from 28 days implementation time-period (September-October 2019) to 9 days during the postimplementation time-period (November 2019-May 2020) (P = 0.0002). Of the first 4 HCW events identified and reviewed as possible HCW SSE events, there were 2 defined as HCW SSE level 4, one defined as a precursor event, and one defined as a nonsafety event. CONCLUSION: Adapting infrastructure and definitions used previously to improve patient safety can improve HCW safety.

The approach to improving patient experience at children's hospitals: a primer for pediatric radiologists.

Increasing attention is being given to improving patient experience in health care. Most children's hospitals have a patient experience office or team that champions and measures patient experience and partners with operations to optimize performance in this area. We outline the activities that our patient experience team undertakes at our pediatric health system to advocate for, measure and improve the experience of our patients and families. The framework we propose for such activities includes those that are proactive in improving patient experience as well as those that are reactive to when patients and families have had a poor experience. Those reactive practices are often centered on the management of patient complaints and grievances and early intervention into patient complaints so that they do not become grievances.

Reduction of Central Line-associated Bloodstream Infection Through Focus on the Mesosystem: Standardization, Data, and Accountability.

INTRODUCTION: Efforts to reduce central line-associated bloodstream infection (CLABSI) rates require strong microsystems for success. However, variation in practices across units leads to challenges in ensuring accountability. We redesigned the organization's mesosystem to provide oversight and alignment of microsystem efforts and ensure accountability in the context of the macrosystem. We implemented an A3 framework to achieve reductions in CLABSI through adherence to known evidence-based bundles. METHODS: We conducted this CLABSI reduction improvement initiative at a 395-bed freestanding, academic, university-affiliated children's hospital. A mesosystem-focused A3 emphasized bundle adherence through 3 key drivers (1) practice standardization, (2) data transparency, and (3) accountability. We evaluated the impact of this intervention on CLABSI rates during the pre-intervention (01/15-09/17) and post-intervention (07/18-06/19) periods using a Poisson model controlling for baseline trends. RESULTS: Our quarterly CLABSI rates during the pre-intervention period ranged from 1.0 to 2.3 CLABSIs per 1,000 central line-days. With the mesosystem in place, CLABSI rates ranged from 0.4 to 0.7 per 1,000 central line days during the post-intervention period. Adjusting for secular trends, we observed a statistically significant decrease in the post versus pre-intervention CLABSI rate of 71%. CONCLUSION: Our hospital-wide CLABSI rate declined for the first time in many years after the redesign of the mesosystem and a focus on practice standardization, data transparency, and accountability. Our approach highlights the importance of alignment across unit-level microsystems to ensure high-fidelity implementation of practice standards throughout the healthcare-delivery system.

Key Drivers in Reducing Hospital-acquired Pressure Injury at a Quaternary Children's Hospital.

INTRODUCTION: Despite being a participating Solutions for Patient Safety (SPS) children's hospital and having attempted implementation of the SPS hospital-acquired pressure injuries (HAPIs) prevention bundle, our hospital remained at a HAPI rate that was 3 times the mean for SPS participating children's hospitals. This performance led to the launch of an enterprise-wide HAPI reduction initiative in our organization. The purpose of this article is to describe the improvement initiative, the key drivers, and the resulting decrease in the SPS-reportable HAPI rate. METHODS: We designed a hospital-wide HAPI reduction initiative with actions grouped into 3 key driver areas: standardization, data transparency, and accountability. We paused all individual hospital unit-based HAPI reduction initiatives. We calculated the rate of SPS-reportable HAPIs per 1,000 patient days during both the pre- and postimplementation phases and compared mean rates using a 2-sided t test assuming unequal variances. RESULTS: The mean SPS-reportable HAPI rate for the preimplementation phase was 0.3489, and the postimplementation phase was 0.0609. The difference in rates was statistically significant (P < 0.00032). This result equates to an 82.5% reduction in HAPI rate. CONCLUSIONS: Having an institutional pause and retooled initiative to reduce HAPI with key drivers in the areas of standardization, data transparency, and accountability had a statistically significant reduction in our organization's SPS-reportable HAPI rate.

Creating a Defined Process to Improve the Timeliness of Serious Safety Event Determination and Root Cause Analysis.

Serious Safety Events (SSEs) are defined as events in which there is a deviation from clinically accepted performance standards, causation, and significant patient harm or death. Given the nature of SSEs, it is important that the processes for declaration of SSEs, the performance of a root cause analysis (RCA), and action plan formation occur quickly, such that the window for potential recurrence of similar events is as small as possible. This manuscript describes a process put in place to improve the timeliness of SSE determination and RCA conduction and evaluates the effect of the process change on these parameters. METHODS: A causal analysis was performed of the baseline process to determine factors contributing to long process times. A new process was created and implemented both for the SSE determination process and the RCA completion process. We calculated the mean time for the pre-implementation phase (April 2016-December 2017) and the post-implementation phase (March 2018-January 2019) for both SSE determination and RCA completion. We evaluated differences with a two-sided t test assuming unequal variances. RESULTS: Comparing pre- versus post- implementation phases, the mean time for SSE determination for events that met the SSE criteria decreased from 38.4 to 4.8 days (P < 0.0001), determination for events that did not meet the SSE criteria decreased from 38.4 to 3.8 days (P < 0.0001), and RCA completion time dropped from 118.0 to 26.2 days (P < 0.0001). CONCLUSIONS: A targeted intervention can significantly reduce SSE determination and RCA conduction times.

Childhood trauma and risk for past and future suicide attempts among women in prison.

PURPOSE: We sought to determine whether childhood trauma is an independent risk factor for past suicide attempts and the future likelihood of attempts among women in prison. METHODS: A random sample of 247 women incarcerated in a state prison in Las Vegas, Nevada, completed a confidential interview that included the Childhood Trauma Questionnaire, the 18-item Brief Symptom Inventory, standard measures of illicit drug use, and the revised Suicidal Behaviors Questionnaire. Multiple logistic regression models were developed to evaluate the independent influence of cumulative childhood trauma on past suicide attempts with intent to die and the future likelihood of suicide attempts. RESULTS: Childhood trauma was frequently reported by female prisoners: emotional abuse (58%), physical abuse (54%), sexual abuse (51%), emotional neglect (53%), and physical neglect (41%). Factors independently associated with past suicide attempts included having a higher childhood trauma score (p < .001), a higher psychological distress score (p=.005), and longer duration of current incarceration (> or =5 years; p=.003). Childhood trauma (p=.05), psychological distress (p < .001), and lack of legal employment before incarceration (p=.05) were independent risk factors for future likelihood of attempting suicide. CONCLUSIONS: Childhood trauma is an independent risk factor for attempted suicide among women in prison that persists into adulthood and cannot fully be attributed to psychological distress, illicit drug use, or incarceration duration. Addressing the emotional impact of childhood trauma among female prisoners may increase the effectiveness of correctional suicide prevention efforts.

Maintaining support in people with paralysis: what works?

Social support is a protective factor for well-being in the risk-and-resilience framework, yet people with paralysis report lower levels of support compared to people without paralysis. Rather than examine deficits, in this study, the authors conducted in-depth interviews with individuals who report high levels of social support to examine what sustains this protective factor. Because relationship equity affects social support, the authors also examined this. They selected participants who reported high levels of support from a survey sample of 299 U.S. adults experiencing some form of paralysis. Seventeen participants completed the in-depth interview. The importance of reciprocity, maintaining autonomy, and a positive outlook for sustaining support were themes identified in the content analysis. In their responses, people with high support emphasized that they do all they can to affect their environment positively, so that ideally, the only assistance that they cannot provide themselves is successfully obtained from others.