Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

A multidisciplinary team from the University of Wisconsin Hospital and Clinics transplant program used failure mode and effects analysis to proactively examine opportunities for communication and handoff failures across the continuum of care from organ procurement to transplantation. The team performed a modified failure mode and effects analysis that isolated the multiple linked, serial, and complex information exchanges occurring during the transplantation of one solid organ. Failure mode and effects analysis proved effective for engaging a diverse group of persons who had an investment in the outcome in analysis and discussion of opportunities to improve the system's resilience for avoiding errors during a time-pressured and complex process.

At-home recovery following hospitalization for bronchiolitis.

OBJECTIVES: To characterize the at-home recovery of infants after hospitalization for bronchiolitis, the impact of recovery from this illness on the family, and the association between delayed infant recovery and parental satisfaction with hospital care. METHODS: Otherwise healthy infants less than 1 year of age admitted to 6 children's hospitals were eligible. Telephone interviews with 486 parents (85% of sampled), 1-2 weeks following discharge, addressed functional recovery, lingering symptoms, family disruption, returns to the emergency department, and parental recall of satisfaction with care. RESULTS: Two thirds of infants experienced difficulties with normal routines (feeding, sleeping, contentedness, liveliness) on the day of discharge. By 5 days at home, 22% continued to experience disruption in sleeping, and 16% in feeding routines. Coughing (56%) and wheezing (27%) were common 4 to 6 days after discharge. Parents who reported longer delays in return to normal family routines took additional time off work, kept their infants out of day care twice as many days, and were more likely to take their infants to the doctor or hospital for repeat medical care. Parents from families slower to return to a normal routine recalled the hospital stay less favorably. CONCLUSIONS: A small but important proportion of infants have a protracted recovery period following hospitalization for bronchiolitis. Delayed recovery is associated with parental work time loss and less favorable parental impressions of care in the hospital. Anticipatory guidance about home recovery could allow parents to plan for extended home care and improve satisfaction with hospital care.

Impact of a bronchiolitis guideline: a multisite demonstration project.

STUDY OBJECTIVES: The purpose of this study was to determine the impact of a multisite implementation of an evidence-based clinical practice guideline for bronchiolitis. DESIGN: Before and after study. SETTING: Eleven Child Health Accountability Initiative (CHAI) study hospitals. PATIENTS: Children < 12 months of age with a first-time episode of bronchiolitis. INTERVENTION: The guideline was implemented in December 1998. Complete preimplementation and postimplementation administrative data on hospital admissions, resource utilization, and length of stay were available from seven study hospitals. At five sites, chart reviews were conducted for data on the number and type of bronchodilators used. MEASUREMENTS AND RESULTS: Complete administrative data were available for 846 historical control subjects and 792 study patients. Length of stay decreased significantly. While the proportion of eligible patients who received any bronchodilator did not change (84%), the proportion of patients who received albuterol decreased from 80 to 75% after guideline implementation (p < 0.03). For patients who received bronchodilators, the mean (+/- SD) number of doses decreased from 13.6 +/- 14.0 to 7.3 +/- 9.1 doses (p < 0.0001). For patients who received albuterol, the mean number of doses decreased from 12.8 +/- 11.8 to 6.4 +/- 7.8 doses (p < 0.0001). Other resource use decreased modestly. Hospital readmission rates within 7 days of discharge were unchanged. CONCLUSIONS: We successfully extended the implementation of an evidence-based clinical practice guideline from one hospital to seven hospitals. Within just a single bronchiolitis season, some significant changes in practice were seen. The multisite CHAI collaborative appears to be a promising laboratory for large-scale quality improvement initiatives.

Assessing medication prescribing errors in pediatric intensive care units.

OBJECTIVE: To evaluate a matrix for determining the predominant type, cause category, and rate of medication prescribing errors, and to explore the effectiveness of hospital-based improvement initiatives among pediatric intensive care units (PICUs). DESIGN: This study involved the prospective identification of medication errors for categorization and evaluation by using a matrix methodology. A pretest-posttest design without a control group was used to explore the impact of initiatives employed to reduce medication error rates and severity. SETTING: PICUs in nine freestanding, collaborating tertiary care children's hospitals that participated in both baseline and postintervention analyses. METHODS: We evaluated 12,026 PICU medication orders at baseline and 9,187 orders postintervention for prescribing errors, excluding resuscitation orders. A standardized tool and process captured error type, cause category, and severity for 2 wks before and after intervention. Three levels of error detection were used and included pharmacy order entry, PICU nurse order transcription, and team-based overview. Site-specific interventions were implemented, which included predominantly provider education as well as informational (47%) and dosing "assists" via preprinted orders, forcing functions, or prompts (39%). RESULTS: Of baseline orders, 11.1% had at least one prescribing error. The interception of prescribing errors improved 30.9% (1.6% of all orders at baseline, 2.0% post intervention). Preventable adverse drug events were uncommon (0.6% of all medication errors) and of low severity at baseline; most were wrong dose errors. The implementation of improvement initiatives, specific for each facility, resulted in a 31.6% reduction in prescribing errors from 11.1% to 7.6%. However, site results varied considerably. CONCLUSIONS: A benchmark for medication prescribing errors in the PICU was identified among nine children's hospitals. The methodology was successful in accounting for site-specific differences with regard to identifying and documenting errors as well as reporting results of improvement initiatives. Furthermore, the methodology employed was generalizable in the identification of predominant prescribing error types, which helped to track individual hospital improvement initiative development and implementation. Overall improvement in prescribing error rates was noted; however, considerable variation in the success of improvement initiatives was noted and bears further attention.

Measuring teamwork and patient safety attitudes of high-risk areas.

Patient care leaders recognize that substantial reductions in health care errors will not come until more attention is given to human solutions, such as improving teamwork in health care teams. The authors introduce a short, valid, and reliable instrument to measure teamwork and patient safety attitudes in hospital high-risk areas, namely the emergency department, the operating room, and the intensive care unit. The instrument was tested among nurses in four hospitals and the results showed that the nurses favored the team approach, while recognizing that teamwork in their departments is not very advanced and that communication with some key team members is problematic. This situation seems ideal for the design of a team training intervention in these settings.