Introduction:Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year.Methods:The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department.Results:Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months.Conclusions:Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.

Current safety efforts in health care use Safety I (find and fix), which has benefits and shortcomings. Safety leaders in multiple industries realize that complex adaptive systems require a new approach—Safety II (proactive safety). Our goal was to develop practical, usable tools to spread Safety II and resilience engineering competencies to clinical frontline staff. Using our prior research and Plan-Do-Study-Act cycles, we developed tools to enhance Safety II competencies that individuals with various backgrounds could understand. Tools address recognizing (Pause to Predict), responding (IDEA), and learning (Feed Forward). These are being taught organizationally in a unit-by-unit sequence. Use of these tools is expected to prompt a shift toward a more proactive mental model of safety that we want our frontline providers to adopt. Coordinating the expertise of bedside clinicians during unprecedented events can safely expand the boundaries of conditions under which we can provide high-quality care by increasing individuals’ and subsequently our systems’ adaptive capacity. We believe this is the first work describing attempts to operationalize Safety II concepts broadly in a health care organization.

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* Abbreviations: ADE — : adverse drug event DDI — : drug-drug interaction Medication errors in pediatric and adult patients occur at similar rates. However, pediatric patients are three times more likely to experience harm as a result of a medication error.1 Significant drug-drug interactions (DDIs) occur that may result in adverse drug events (ADEs) sometimes leading to patient harm.2 DDIs cause patient harm by altering medication effectiveness or increasing the potential for toxicity.3 We applaud Antoon et al4 for examining the prevalence, identifying pediatric DDI risk factors, and prescribing practice variation associated with significant DDIs in patients hospitalized in US children’s hospitals. In their study, they describe “what is.” Their results are not surprising and, importantly, the information provides a platform for driving improved outcomes. We agree with the authors that the next steps should include focused efforts to identify DDI-related harm in children and subsequent interventions to prevent such harm. Specifically, additional studies to prevent DDIs should include mitigation strategies children’s hospitals are using or could use to reduce DDIs with a focus on the impact these mitigations have on preventable harm. There are items in the article by Antoon et al4 that require clarification and further discussion. First, newborns and infants in … Address correspondence to Jenna Merandi, PharmD, MS, CPPS, Department of Pharmacy, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205. E-mail: jenna.merandi{at}nationwidechildrens.org

PURPOSE:As health systems continue to expand pharmacy and clinical services, the ability to evaluate potential medication safety risks and mitigate errors remains a high priority. Workload and productivity monitoring tools for the assessment of operational and clinical pharmacy services exist. However, such tools are not currently available to justify medication safety pharmacy services. The purpose of this study is to determine methods used to assess, allocate, and justify medication safety resources in pediatric hospitals.METHODS:A 32-question survey was designed and distributed utilizing the Research Electronic Data Capture (REDCap) tool. The survey was disseminated to 46 pediatric hospitals affiliated with the Children's Hospital Association (CHA). The survey was distributed in October 2018, and the respondents were given 3 weeks to submit responses. Data analysis includes the use of descriptive statistics. Categorical variables were summarized by frequencies and percentages to distinguish the differences between pediatric health systems.RESULTS:Of 26 respondents, 15.4% utilized metrics to justify medication safety resources. Metrics utilized were based on medication dispenses, projects, and error coding. Twenty-three percent of respondents were dissatisfied with current pharmacy-based medication safety resources within the organization. There was variability of medication safety resources within pediatric hospitals, including the number of dedicated full-time equivalents, time spent on tasks, and task prioritization.CONCLUSION:Assessing medication safety resources at various pediatric hospitals highlights several potential barriers and opportunities. This information will serve as the foundation for the creation of a standardized workload assessment tool to assist pharmacy leaders with additional resource justification.

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.

Our goal is to review a number of methodologies which have been used to improve safety in healthcare since the release of the Institute of Medicine report in 1998 which documented that error was a significant cause of mortality in the USA. Multifaceted approaches have each led to reduction in error. Methods for error reduction included in this review are “Just Culture,” increased transparency and accountability, error reporting and investigation, second-victim programs, training in quality and safety methods, standardization and bundles, electronic health records, computerized order entry, barcode scanning, clinical decision support, predictive analytics, and situational awareness. Newer fields with the potential to improve patient safety include human factors engineering, indication-based prescribing, and Safety II. While each intervention has led to incremental improvement, continued expansion of these programs is necessary to eliminate medical error.

INTRODUCTION:Opioid abuse in the United States is a public health emergency. From 2000 to 2009, prenatal maternal opiate use increased from 1.19 to 5.63 per 1,000 births, with up to 80% of in utero opioid-exposed infants requiring pharmacotherapy. This study aimed to increase the percentage of neonatal abstinence syndrome (NAS) medication orders based on birth weight (BW) in neonates admitted to a neonatal intensive care unit with a principal diagnosis of NAS from 29% to 90%, within 4 months of project initiation, and to sustain this for 6 months.METHODS:This project occurred at an academic medical center with 5,000 deliveries per year and a 49-bed Level III neonatal intensive care unit. We used the Institute for Healthcare Improvement methodology, largely focusing interventions on clinical decision support (CDS) tools. We plotted all measures on Shewhart charts, and Nelson rules differentiated special versus common cause variation.RESULTS:The percent of orders based on BW increased from 29% to 78% after implementing multiple interventions focused primarily on CDS. However, this later decreased to 48% as workarounds began. There was also a significant decrease in the length of stay variability, which persisted throughout the project.DISCUSSION:CDS is a helpful tool to guide prescribing behavior; however, workarounds can negate its usefulness. Standardized use of BW for weight-based NAS medication prescribing can decrease the length of stay variability. Further studies are needed using a human factors approach to minimize workarounds in CDS and potentially decrease the length of stay in neonates with NAS.

BACKGROUND AND OBJECTIVES There has been slow adoption of electronic prescribing of controlled substances (EPCS) due to cost concerns and cumbersome technological and security specifications required by the DEA. The objective of this study was to assess the effects of an EPCS implementation at a tertiary care pediatric hospital on prescribing patterns and providers’ perceptions of this functionality pre and post implementation. METHODS The prescribing patterns of both the pilot group and the institution as a whole were analyzed before and after implementation. A survey was distributed to …

BACKGROUND AND OBJECTIVE: Safety I error elimination concepts are focused on retrospectively investigating what went wrong and redesigning system processes and individual behaviors to prevent similar future occurrences. The Safety II approach recognizes complex systems and unpredictable circumstances, mandating flexibility and resilience within systems and among individuals to avoid errors. We hypothesized that in our high-complexity and high-risk PICU, Safety II concepts contribute to its remarkably low adverse drug event rate. Our goal was to identify how this microsystem enacts Safety II. METHODS: We conducted multidisciplinary focus group sessions with PICU members using nonleading, open-ended questions to elicit free-form conversation regarding how safety occurs in their unit. Qualitatively analyzing transcripts identified system characteristics and behaviors potentially contributing to low adverse drug event rates in PICU. Researchers skilled in qualitative methodologies coded transcripts to identify key domains and common themes. RESULTS: Four domains were identified: (1) individual characteristics, (2) relationships and interactions, (3) structural and environmental characteristics, and (4) innovation approaches. The themes identified in the first 3 domains are typically associated with Safety I and adapted for Safety II. Themes in the last domain (innovation approaches) were specific to Safety II, which were layered on Safety I to improve results under unusual situations. CONCLUSIONS: Safety II behavior in this unit was based on strong Safety I behaviors adapted to the Safety II environment plus innovation behaviors specific to Safety II situations. We believe these behaviors can be taught and learned. We intend to spread these concepts throughout the organization.

Background While research has established the negative impact of medical errors or adverse events on healthcare providers, few organizations have evaluated support programs for second victims. Thus, we examined satisfaction with a peer support program to provide lessons learned from early implementation. Methods Participants ( N = 466) were recruited from seven neonatal intensive care units affiliated with a large, pediatric hospital. Following implementation of a peer support program, a mixed-method online survey assessed program satisfaction at 12 month follow-up ( n = 250, 54%). Results Most participants were female ( n = 243, 97%), white ( n = 239, 96%), and nurses ( n = 180, 72%), with an average age of 40.80 (SD = 11.89) years. Ninety-three (37%) participants observed or were directly involved in an error or adverse event during the preceding six months. Thirty-six (14%) received support from someone within the neonatal intensive care unit, and 16 (16%) had spoken with a peer supporter after the event. All users reported benefit from the interaction. However, most participants were unaware of the program or had not utilized it. Conclusion Findings suggested that peer support programs are likely to be viewed favorably by second victims. Healthcare providers who accessed the program felt it was a valuable resource and helped them return to work effectively after an error or adverse event. Better communication is needed during early implementation of any peer support program to increase awareness and use of this resource among healthcare providers.

BACKGROUND:The second victim phenomenon occurs when health-care providers experience significant professional distress (compassion dissatisfaction, burnout, secondary traumatic stress) and psychological distress (shame, anxiety, and depression) as a result of medical errors or adverse patient outcomes. Few hospitals have institution-wide systems in place to assist employees through the recovery process.METHODS:At Nationwide Children's Hospital (NCH), a peer-based support program called "YOU Matter" was executed and spread hospital-wide. The program emulated the framework and execution strategy designed by University of Missouri Health Care's (MUHC) "forYOU" Team. Strategic elements of the program's structure were reviewed and adapted for NCH with system-wide deployment and enhancement to include electronic peer support reporting. This article summarizes program implementation, management, and sustainment over the past 2 years.RESULTS:By following University of Missouri Health Care's model, we successfully deployed an institution-wide second victim program. Since the November 2013 initiation, we have documented 232 peer and 21 group encounters. High-risk clinical areas for second victimization at NCH included the emergency department (ED), pediatric intensive care unit (PICU), cardiothoracic intensive care unit (CTICU), and pharmacy department. Registered nurses (RNs) and licensed practical nurses (LPNs) have had the highest number of encounters necessitating second victim support (32%). Supported staff reported improved emotional state and improved return-to-work metrics.CONCLUSIONS:An organization's culture of patient safety can be enhanced by ensuring staff psychological safety. Programs like "YOU Matter" and the "forYOU" Team are essential building blocks to improve the overall safety culture and quality of care. Implementation of "YOU Matter" at NCH validates the MUHC program and demonstrates its generalizability to other health-care institutions.

AIMS:To examine the impact of errors or adverse events on emotional distress and professional quality of life in healthcare providers in the neonatal intensive care unit, and the moderating role of coworker support.BACKGROUND:Errors or adverse events can result in negative outcomes for healthcare providers. However, the role of coworker support in improving emotional and professional outcomes has not been examined.DESIGN:A cross-sectional online survey from a quality improvement initiative to train peer supporters in a neonatal intensive care unit.METHODS:During 2015, 463 healthcare providers in a neonatal intensive care unit completed a survey assessing their experiences with an error or adverse event, anxiety, depression, professional quality of life and coworker support.RESULTS:Compared with those who did not experience an error or adverse event (58%), healthcare providers who observed (23%) or were involved (19%) in an incident reported higher levels of anxiety and secondary traumatic stress. Those who were involved in an event reported higher levels of depression and burnout. Differences between the three groups (no event, observation and involvement) for compassion satisfaction were non-significant. Perceived coworker support moderated the association between experiencing an event and both anxiety and depression. Specifically, experiencing an event was associated with higher levels of anxiety and depression when coworkers were perceived as low in supportiveness, but not when they were viewed as highly supportive.CONCLUSION:Findings suggest that errors or adverse events can have a harmful impact on healthcare providers and that coworker support may reduce emotional distress.

Purpose. A pharmacy student-driven discharge service developed for patients to reduce the number of medication errors on after-visit summaries (AVSs) is discussed.Methods. An audit of AVS documents was conducted before the implementation period (September 3 to October 23, 2013) to identify medication errors. As part of the audit, a pharmacist review of the discharge medication list was completed to determine the number and types of errors that occurred. A student-driven discharge service with AVS review was developed in collaboration with nursing and medical residents. Students reviewed a patient's AVS, delivered the discharge prescriptions to bedside, and conducted medication reconciliation with the patient and family. The AVS audit was conducted after implementation of these services to assess the impact on medication errors.Results. It was observed that 72% (108 of 150) of AVSs contained at least 1 error before discharge and AVS review. During the 2-month postimplementation period (September 3 to October 23, 2014), this decreased to 27% (34 of 127), resulting in a 52% absolute reduction in the number of AVSs with at least 1 medication error (p < 0.0001). The most common error was as-needed medication with no indication, which decreased from 55% in the preimplementation audit to 16% in the postimplementation audit. Prescribing to Nationwide Children's Hospital's outpatient pharmacy increased from 57% in the preimplementation period to 73% in the postimplementation period for the general pediatrics service.Conclusion. A pharmacy student-driven discharge and medication delivery service reduced the number of AVSs and increased access to medications for patients.

BACKGROUND Inter-professional education is now a required element of the 2016 ACPE guidelines. “Medication use” is also an identified in all six core competencies from the ACGME. Medical curricula generally include a single semester of pharmacology, and pharmacotherapy is often a topic subset of this or of pathophysiology. Since 70% of medication errors in primary care can be related to prescribing issues, it seems prudent for pharmacists and physicians to learn collaboratively. 4,5 A few pharmacist-led experiential rotations for medical residents have been described in the literature, but to date, none are co-educational or specifically address cognitive processes in clinical decision-making.

PURPOSE:The reduction of immunization errors through the use of age-specific alerts within the electronic medical record (EMR) and mandatory interactive education for prescribers is described.METHODS:A health system-wide initiative was implemented at an academic pediatric hospital to reduce the number of immunization errors. The preimplementation period (January 1-December 31, 2013) involved a baseline review of adverse drug events (ADEs) reported through a voluntary event reporting system to determine the number and types of immunization errors. During the prescribing phase of the medication-use process, 57% (43 of 75) of errors occurred. First, age-based restrictions were implemented within the EMR. This was followed by mandatory immunization education for all prescribers working in the primary care network. Data collection included all reported vaccine errors within the voluntary event reporting system and completion rates of education by physicians, nurse practitioners, and medical residents.RESULTS:During the seven-month postimplementation period (January 1- July 31, 2014), prescribing events decreased from 57% to 25%. Following implementation of age-specific immunization alerts and mandatory prescriber education, the hospital went 175 days without a vaccine ADE.CONCLUSION:The implementation of age-specific alerts within the EMR and mandatory prescriber education decreased the number of immunization errors within a pediatric health system.