Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm

Introduction

Significant adverse drug events (ADEs) due to anesthesia infusion pump programming errors were reported at our institution. We incorporated independent two-provider infusion pump programming verification, an evidence-supported intervention, into our anesthesia medication infusion process with a goal of reducing associated ADEs to zero in 2 years.

Methods

Using the model for improvement, we developed key drivers and interventions and utilized plan-do-study-act (PDSA) cycles. Drivers included education and training, verification process, visual aids, information technology, and safety culture. Interventions included anesthesia provider training, information dissemination, independent two-provider verification process of smart pump programming, verification documentation capability, verification compliance tracking, and visual aids. Our outcome measures were relevant ADEs and near-miss events. Process and balancing measures were the percentage of smart pump programs with independent second verification and delayed case starts due to second provider verification, respectively.

Results

During the project period, only one related grade E ADE occurred, and the root cause was not conducting an independent pump programming verification. Thirteen grade B near-miss events were prevented due to independent second verification. Second verification adherence reached 85% and was sustained, and no delayed case starts occurred.

Conclusions

With structured quality improvement methods, the process of independent two-provider verification of infusion pump programming during anesthesia can be successfully implemented, and errors in a high-volume setting reduced without negatively affecting case start times. The cultural and organizational factors we report may aid other institutions in gaining project buy-in and sustainment.

Quality improvement knowledge in pediatric hematology/oncology physicians: A need for improved education

Pediatric hematology/oncology fellows face unique quality improvement challenges given the danger of chemotherapy and caring for immunocompromised patients. Curricula to teach pediatric hematology/oncology fellows about quality improvement are lacking. We conducted a needs assessment of pediatric hematology/oncology physicians as a first step for creating a quality improvement curriculum for pediatric hematology/oncology fellows. Curricular topics were identified: root cause analysis, run charts, process mapping, chemotherapy/medication safety, implementation/adherence to guidelines. Identified barriers to curriculum implementation included a possible lack of quality improvement expertise, lack of awareness of quality improvement resources, and limited time.

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.

Associations of job demands and patient safety event involvement on burnout among a multidisciplinary group of pediatric hematology/oncology clinicians

BACKGROUND

Workplace burnout can result in negative consequences for clinicians and patients. We assessed burnout prevalence and sources among pediatric hematology/oncology inpatient nurses, ambulatory nurses, physicians (MDs), and advanced practice providers (APPs) by evaluating effects of job demands and involvement in patient safety events (PSEs).

METHODS

A cross-sectional survey (Maslach Burnout Inventory) measured emotional exhaustion, depersonalization, and reduced personal accomplishment. The National Aeronautics and Space Administration Task Load Index measured mental demand, physical demand, temporal demand, effort, and frustration. Relative weights analyses estimated the unique contributions of tasks and PSEs on burnout. Post hoc analyses evaluated open-response comments for burnout factors.

RESULTS

Burnout prevalence was 33%, 20%, 34%, and 33% in inpatient nurses, ambulatory nurses, and MD, and APPs, respectively (N = 481, response rate 69%). Reduced personal accomplishment was significantly higher in inpatient nurses than MDs and APPs. Job frustration was the most significant predictor of burnout across all four cohorts. Other significant predictors of burnout included temporal demand (nursing groups and MDs), effort (inpatient nurses and MDs), and PSE involvement (ambulatory nurses). Open-response comments identified time constraints, lack of administrator support, insufficient institutional support for self-care, and inadequate staffing and/or turnover as sources of frustration.

CONCLUSIONS

All four clinician groups reported substantial levels of burnout, and job demands predicted burnout. The body of knowledge on job stress and workplace burnout supports targeting organizational-level sources versus individual-level factors as the most effective prevention and reduction strategy. This study elaborates on this evidence by identifying structural drivers of burnout within a multidisciplinary context of pediatric hematology/oncology clinicians.

Never Enough Time: Mixed Methods Study Identifies Drivers of Temporal Demand That Contribute to Burnout Among Physicians Who Care for Pediatric Hematology-Oncology Patients

PURPOSE

Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment because of chronic occupational stress. Approximately one third of pediatric hematology-oncology physicians experience burnout. The goal of this mixed methods study was to determine the prevalence and drivers of burnout among physicians caring for pediatric hematology-oncology patients at our institution.

MATERIALS AND METHODS

This mixed methods, cross-sectional study was conducted at a large academic cancer center. Validated survey instruments were used to measure burnout, job demands, experience with patient safety events, and workplace culture. Quantitative data informed development of a semistructured interview guide, and physicians were randomly selected to participate in individual interviews. Interviews were transcribed and analyzed via content analysis based on a priori codes.

RESULTS

The survey was distributed to 132 physicians, and 53 complete responses were received (response rate 40%). Of the 53 respondents, 15 (28%) met criteria for burnout. Experiencing burnout was associated with increased temporal demand. Twenty-six interviews were conducted. Qualitative themes revealed that frequent meetings, insufficient support staff, and workflow interruptions were key drivers of temporal demand and that temporal demand contributed to burnout through emotional exhaustion and reduced personal accomplishment.

CONCLUSION

Nearly one-third of participating physicians met criteria for burnout, and burnout was associated with increased temporal demand. Qualitative interviews identified specific drivers of temporal demand and burnout, which can be targeted for intervention. This methodology can be easily adapted for broad use and may represent an effective strategy for identifying and mitigating institution-specific drivers of burnout.

The Effects of the Second Victim Phenomenon on Work-Related Outcomes: Connecting Self-Reported Caregiver Distress to Turnover Intentions and Absenteeism

OBJECTIVES

Second victim experiences can affect the well-being of healthcare providers and compromise patient safety. The purpose of this study was to assess the relationships between self-reported second victim-related distress to turnover intention and absenteeism. Organizational support was examined concurrently because it was hypothesized to explain the potential relationships between distress and work-related outcomes.

METHODS

A cross-sectional, self-report survey (the Second Victim Experience and Support Tool) of nurses directly involved in patient care (N = 155) was analyzed by using hierarchical linear regression. The tool assesses organizational support, distress due to patient safety event involvement, and work-related outcomes.

RESULTS

Second victim distress was significantly associated with turnover intentions (P < 0.001) and absenteeism (P < 0.001), while controlling for the effects of demographic variables. Organizational support fully mediated the distress-turnover intentions (P < 0.05) and distress-absenteeism (P < 0.05) relationships, which indicates that perceptions of organizational support may explain turnover intentions and absenteeism related to the second victim experience.

CONCLUSIONS

Involvement in patient safety events and the important role of organizational support in limiting caregiver event-related trauma have been acknowledged. This study is one of the first to connect second victim distress to work-related outcomes. This study reinforces the efforts health care organizations are making to develop resources to support their staff after patient safety events occur. This study broadens the understanding of the negative effects of a second victim experience and the need to support caregivers as they recover from adverse event involvement.

Improving Patient Handoffs and Transitions through Adaptation and Implementation of I-PASS Across Multiple Handoff Settings

INTRODUCTION

Communication failures are common root causes of serious medical errors. Standardized, structured handoffs improve communication and patient safety. I-PASS is a handoff program that decreases medical errors and preventable patient harm. The I-PASS mnemonic is defined as illness severity, patient information, action list, situational awareness and contingency plans, and synthesis by receiver. I-PASS was validated for physician handoffs, yet has the potential for broader application. The objectives of this quality improvement initiative were to adapt and implement I-PASS to handoff contexts throughout a pediatric hospital, including those with little or no known evidence of using I-PASS.

METHODS

We adapted and implemented I-PASS for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff. Throughout the initiative, end-user stakeholders participated as team members and informed the adaptation of the I-PASS mnemonic, handoff processes, written handoff documents, and performance evaluation methods. Peers observed handoffs, scored performance, and provided formative feedback. Adherence to I-PASS was the primary outcome. We also evaluated changes in handoff-related error frequency and clinician attitudes about the effects of I-PASS on personal and overall handoff performance.

RESULTS

All 5 elements of the I-PASS mnemonic were used in 87% of inpatient nursing, 76% of physician, and 89% of imaging/procedures handoffs. Inpatient nurses reported reductions in handoff-related errors following I-PASS implementation. Clinicians across most handoff settings reported that using I-PASS improved both general and personal handoff performance.

CONCLUSIONS

I-PASS is adaptable to many handoff settings, which expands its potential to improve patient safety. Clinicians reported reductions in errors and improvements in handoff performance. We identified broad institutional support, customized written handoff documents, and peer observations with feedback as crucial factors in sustaining I-PASS usage.

A quality improvement project to improve pediatric medical provider sleep and communication during night shifts

QUALITY PROBLEM OR ISSUE

Night-shift medical providers frequently experience limited sleep resulting in fatigue, often because of paging activity. Streamlined medical-specific communication interventions are known to improve sleep and communication among these providers.

INITIAL ASSESSMENT

We found that non-urgent paging communication occurred frequently during night-shifts, leading to provider sleep disturbances within our institution. We tested a quality improvement (QI) intervention to improve paging practices and determined its effect on provider sleep.

CHOICE OF SOLUTION

We used a Plan-Do-Study-Act QI model aimed at improving clinician sleep and paging communications.

IMPLEMENTATION

We initially conducted focus groups of nurses and physician trainees to inform the creation of a standardized paging intervention. We collected actigraphy and sleep log data from physicians, nurse practitioners, and physician trainees and performed electronic collection of paging frequency data.

EVALUATION

Data were collected between December 2015 and March 2017 from pediatric residents, pediatric hematology/oncology (PHO) fellows, hospitalist medicine nocturnists and nurses working during night-shift hours in PHO inpatient units. We collected baseline data before implementation of the QI intervention and at 1 month post-implementation. Although objective measures and provider reports demonstrated improved medical-specific communication paging practices, provider sleep was not affected.

LESSONS LEARNED

Provider-based standardization of paging communication was associated with improved medical-specific communication between nurses and providers; however, provider sleep was not affected. The strategies used in this intervention may be transferable to other clinics and institutions to streamline medical-specific communication.

Optimizing Drug-Drug Interaction Alerts Using a Multidimensional Approach

OBJECTIVES

Excessive alerts are a common concern associated with clinical decision support systems that monitor drug-drug interactions (DDIs). To reduce the number of low-value interruptive DDI alerts at our hospital, we implemented an iterative, multidimensional quality improvement effort, which included an interdisciplinary advisory group, alert metrics, and measurement of perceived clinical value.

METHODS

Alert data analysis indicated that DDIs were the most common interruptive medication alert. An interdisciplinary alert advisory group was formed to provide expert advice and oversight for alert refinement and ongoing review of alert data. Alert data were categorized into drug classes and analyzed to identify DDI alerts for refinement. Refinement strategies included alert suppression and modification of alerts to be contextually aware.

RESULTS

On the basis of historical analysis of classified DDI alerts, 26 alert refinements were implemented, representing 47% of all alerts. Alert refinement efforts resulted in the following substantial decreases in the number of interruptive DDI alerts: 40% for all clinicians (22.9-14 per 100 orders) and as high as 82% for attending physicians (6.5-1.2 per 100 orders). Two patient safety events related to alert refinements were reported during the project period.

CONCLUSIONS

Our quality improvement effort refined 47% of all DDI alerts that were firing during historical analysis, significantly reduced the number of DDI alerts in a 54-week period, and established a model for sustained alert refinements.

Using EHR Data to Detect Prescribing Errors in Rapidly Discontinued Medication Orders

BACKGROUND

Previous research developed a new method for locating prescribing errors in rapidly discontinued electronic medication orders. Although effective, the prospective design of that research hinders its feasibility for regular use.

OBJECTIVES

Our objectives were to assess a method to retrospectively detect prescribing errors, to characterize the identified errors, and to identify potential improvement opportunities.

METHODS

Electronically submitted medication orders from 28 randomly selected days that were discontinued within 120 minutes of submission were reviewed and categorized as most likely errors, nonerrors, or not enough information to determine status. Identified errors were evaluated by amount of time elapsed from original submission to discontinuation, error type, staff position, and potential clinical significance. Pearson's chi-square test was used to compare rates of errors across prescriber types.

RESULTS

In all, 147 errors were identified in 305 medication orders. The method was most effective for orders that were discontinued within 90 minutes. Duplicate orders were most common; physicians in training had the highest error rate (p < 0.001), and 24 errors were potentially clinically significant. None of the errors were voluntarily reported.

CONCLUSION

It is possible to identify prescribing errors in rapidly discontinued medication orders by using retrospective methods that do not require interrupting prescribers to discuss order details. Future research could validate our methods in different clinical settings. Regular use of this measure could help determine the causes of prescribing errors, track performance, and identify and evaluate interventions to improve prescribing systems and processes.

Standardizing terms for clinical pharmacogenetic test results: consensus terms from the Clinical Pharmacogenetics Implementation Consortium (CPIC)

INTRODUCTION

Reporting and sharing pharmacogenetic test results across clinical laboratories and electronic health records is a crucial step toward the implementation of clinical pharmacogenetics, but allele function and phenotype terms are not standardized. Our goal was to develop terms that can be broadly applied to characterize pharmacogenetic allele function and inferred phenotypes.

MATERIALS AND METHODS

Terms currently used by genetic testing laboratories and in the literature were identified. The Clinical Pharmacogenetics Implementation Consortium (CPIC) used the Delphi method to obtain a consensus and agree on uniform terms among pharmacogenetic experts.

RESULTS

Experts with diverse involvement in at least one area of pharmacogenetics (clinicians, researchers, genetic testing laboratorians, pharmacogenetics implementers, and clinical informaticians; n = 58) participated. After completion of five surveys, a consensus (>70%) was reached with 90% of experts agreeing to the final sets of pharmacogenetic terms.

DISCUSSION

The proposed standardized pharmacogenetic terms will improve the understanding and interpretation of pharmacogenetic tests and reduce confusion by maintaining consistent nomenclature. These standard terms can also facilitate pharmacogenetic data sharing across diverse electronic health care record systems with clinical decision support.Genet Med 19 2, 215-223.

Alert dwell time: introduction of a measure to evaluate interruptive clinical decision support alerts

Metrics for evaluating interruptive prescribing alerts have many limitations. Additional methods are needed to identify opportunities to improve alerting systems and prevent alert fatigue. In this study, the authors determined whether alert dwell time-the time elapsed from when an interruptive alert is generated to when it is dismissed-could be calculated by using historical alert data from log files. Drug-drug interaction (DDI) alerts from 3 years of electronic health record data were queried. Alert dwell time was calculated for 25,965 alerts, including 777 unique DDIs. The median alert dwell time was 8 s (range, 1-4913 s). Resident physicians had longer median alert dwell times than other prescribers (P < 001). The 10 most frequent DDI alerts (n = 8759 alerts) had shorter median dwell times than alerts that only occurred once (P < 001). This metric can be used in future research to evaluate the effectiveness and efficiency of interruptive prescribing alerts.

Risk screening for ADHD in a college population: is there a relationship with academic performance?

OBJECTIVE

The present study examines the relationship between self-reported levels of ADHD and academic outcomes, as well as aptitude.

METHOD

A total of 523 college students took the Adult Self-Report Scale-Version 1.1 (ASRS-V1.1), and their scores were compared with course performance and ACT (American College Test) composite scores.

RESULTS

The measure identified 70 students (13.4%) as being in the "highly likely" category for an ADHD diagnosis. Course exam and ACT scores for the 70 "highly likely" students were statistically identical to the remaining 453 students in the sample and the 77 students identified as "highly unlikely" as well. Only 4 of the "highly likely" 70 students were registered with the university's Office of Student Disability Services as having been diagnosed with ADHD.

CONCLUSIONS

The ASRS-V1.1 failed to discriminate academic performance and aptitude differences between ADHD "highly likely" and "highly unlikely" individuals. The use of self-report screeners of ADHD is questioned in contexts relating ADHD to academic performance.