Safety Rounds in Ambulatory and Inpatient Settings

Wednesday, October 25, 200612:00 – 1:00 p.m. EDT

Moderator: Uma Kotagal, MD, MBBS, MSCE, FAAPVice President for Quality and TransformationDirector, Center for Health Policy & Clinical

EffectivenessCincinnati Children’s Hospital Medical CenterCincinnati, Ohio

This activity was funded through an educational grant from the

Physicians’ Foundation for Health Systems Excellence.

Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities Grid

The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional performance of pediatric healthcare professionals by providing high quality, relevant, accessible and cost-effective educational experiences. The AAP CME program provides activities to meet the participants’ identified education needs and to support their lifelong learning towards a goal of improving care for children and families (AAP CME Program Mission Statement, August 2004).

The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest.

All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity.

The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is committed to providing learners with commercially unbiased CME activities.

DISCLOSURESActivity Title: Safer Health Care for Kids - Webinar Safety Rounds in Ambulatory and Inpatient Settings Activity Date: October 25, 2006

DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing health

care goods or services)

Nature of Relevant Financial

Relationship(s) (If yes, please list: Research Grant,

Speaker’s Bureau, Stock/Bonds excluding

mutual funds, Consultant, Other -

identify)

CME Content Will Include Discussion/

Reference to Commercial

Products/Services

Disclosure of Off-Label (Unapproved)/Investigational Uses of Products

AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or demonstrate

pharmaceuticals and/or medical devices that are not approved

Kathy N. Shaw, MD, MSCE, FAAP

No No No No

Sara J. Singer, MBA No No No No

DISCLOSURESSAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMMITTEE AND STAFF DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing health care goods

or services)

Nature of Relevant Financial Relationship(s)

(If yes, please list: Research Grant, Speaker’s

Bureau, Stock/Bonds excluding mutual funds,

Consultant, Other - identify)

CME Content Will Include Discussion/

Reference to Commercial Products/Services

Disclosure of Off-Label (Unapproved)/Investigational Uses

of Products AAP CME faculty are required to

disclose to the AAP and to learners when they plan to discuss or

demonstrate pharmaceuticals and/or medical devices that are not approved

Karen Frush, MD, FAAP (PAC Member)

No No No No

Uma Kotagal, MD, MBBS, MSc, FAAP (PAC Member)

No No No No

Christopher Landrigan, MD, MPH, FAAP (PAC Member)

No No No No

Marlene R. Miller, MD, MSc, FAAP (PAC Chair)

No No No No

Paul Sharek, MD, MPH. FAAP (PAC Member)

No No No No

Erin Stucky, MD, FAAP (PAC Member)

No No Not sure No

Nancy Nelson (AAP Staff) No No No No

Melissa Singleton, MEd (Project Manager – AAP Consultant)

No No No No

Junelle Speller (AAP Staff) No No No No

Linda Walsh, MAB (AAP Staff)

No No No No

DISCLOSURESAAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME) DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing health care goods

or services)

Nature of Relevant Financial Relationship(s)

(If yes, please list: Research Grant, Speaker’s

Bureau, Stock/Bonds excluding mutual funds,

Consultant, Other - identify)

CME Content Will Include Discussion/

Reference to Commercial Products/Services

Disclosure of Off-Label (Unapproved)/Investigational Uses

of Products AAP CME faculty are required to

disclose to the AAP and to learners when they plan to discuss or

demonstrate pharmaceuticals and/or medical devices that are not approved

Ellen Buerk, MD, FAAP

No No No No

Meg Fisher, MD, FAAP

No No No No

Robert A. Wiebe, MD, FAAP

No No Not sure No

Jack Dolcourt, MD, FAAP

No No No No

Thomas W. Pendergrass, MD, FAAP

No No No No

Beverly P. Wood, MD, FAAP No No No No

CME CREDIT

The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

 The AAP designates this educational activity for a

maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

 This activity is acceptable for up to 1.0 AAP credit.

This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

OTHER CREDIT

This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 0.0 contain pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2633.

 The American Academy of Physician Assistants

accepts AMA PRA Category 1 Credit(s)TM from organizations accredited by the ACCME .

Featured Speaker: Kathy N. Shaw, MD, MSCE, FAAPChief, Division of Emergency MedicineThe Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania

OBJECTIVESUpon completion of this activity, participants will be able to: Describe the process and explain the rationale

for senior leader-driven Safety Rounds in ambulatory and inpatient settings.

List the types of safety issues identified on Safety Rounds, and distinguish similarities and differences between safety issues in ambulatory and inpatient settings.

Select and apply at least one strategy to ensure issues identified on Safety Rounds are efficiently and effectively discussed with all appropriate individuals and improvements are implemented.

The Children’s Hospital of Philadelphia The Children’s Hospital of Philadelphia Emergency Department Emergency Department

Unit-Based Patient Safety WalkRoundsUnit-Based Patient Safety WalkRounds

Kathy N. Shaw, M.D., M.S.C.E.Kathy N. Shaw, M.D., M.S.C.E.

Chief, Division of Emergency MedicineChief, Division of Emergency Medicine

Professor of Pediatrics at CHOPProfessor of Pediatrics at CHOP

University of Pennsylvania School of MedicineUniversity of Pennsylvania School of Medicine

The Nicholas Crognale Endowed ChairThe Nicholas Crognale Endowed Chair

in Pediatric Emergency Medicinein Pediatric Emergency Medicine

Purpose of WalkRoundsPurpose of WalkRounds• Mechanism for communicating with staff Mechanism for communicating with staff

about safety issuesabout safety issues

• Signal staff on the front lines that there is Signal staff on the front lines that there is commitment to a culture of safetycommitment to a culture of safety

• Foster open communication andFoster open communication anda blame-free environmenta blame-free environment

• Gather ideas to take action to make Gather ideas to take action to make a safer work placea safer work place

Unit-basedUnit-based PSWR PSWR

• Stakeholders vs. visitorsStakeholders vs. visitors

• Ubiquitous vs. sporadicUbiquitous vs. sporadic

• Rapid response and dissemination Rapid response and dissemination of information vs. not . . .of information vs. not . . .

When:When: Unit-based Unit-based PSWR PSWR

• Minimum of 2 times / monthMinimum of 2 times / month

• All days of the weekAll days of the week

• All times of the dayAll times of the day

Participants: Participants: Unit-basedUnit-based PSWR PSWR

• Team leaders:Team leaders:

– PEM attending / 2 RNsPEM attending / 2 RNs

• Staff Participants:Staff Participants:

– ResidentResident

– ED nurseED nurse

– Clerical staffClerical staff

– Social worker or Child Life therapistSocial worker or Child Life therapist

– Respiratory therapist or Radiology techRespiratory therapist or Radiology tech

– Environmental Services or ED techEnvironmental Services or ED tech

Where: Where: Unit-basedUnit-based PSWR PSWR

• CQI in patient care area of the ED (15-20 min)CQI in patient care area of the ED (15-20 min)

• Group meeting in the ED conference room Group meeting in the ED conference room

(15-20 min)(15-20 min)

Tool Kit: Tool Kit: Unit-basedUnit-based PSWR PSWR

• Step by Step Guide to Conducting PSWRStep by Step Guide to Conducting PSWR

• Quality Improvement Indicator ToolsQuality Improvement Indicator Tools

• General Questions for Group DiscussionGeneral Questions for Group Discussion

ED Based CQI ActivitiesED Based CQI Activities

• 4 team members complete CQI tools in ED4 team members complete CQI tools in ED

– Clinical observationsClinical observations

– Interviews with staff / parentsInterviews with staff / parents

– Review of chart, electronic tracking andReview of chart, electronic tracking and ordering systemordering system

Quality Improvement ToolsQuality Improvement Tools

1.1. Accuracy of weight and allergy documentationAccuracy of weight and allergy documentation RN or tech joins PSWRRN or tech joins PSWR

2.2. Appropriateness of patient monitoring Appropriateness of patient monitoring and alarm parameters /and alarm parameters / central monitoringcentral monitoring

RN joins PSWRRN joins PSWR

3.3. Reasons for prolonged ED length of stayReasons for prolonged ED length of stay > 3 hrs> 3 hrs

Resident joins PSWRResident joins PSWR

Quality Improvement ToolsQuality Improvement Tools4.4. Accuracy of medication orders, administration, Accuracy of medication orders, administration,

and documentation and documentation

ED RN or MD joins PSWRED RN or MD joins PSWR

5. Compliance with hand washing5. Compliance with hand washing

RN joins PSWR; person from Environmental Services RN joins PSWR; person from Environmental Services

identified to complete room check part of QIidentified to complete room check part of QI

6. Patient / family communication (directed at patient/caregiver)6. Patient / family communication (directed at patient/caregiver)

Clerk or Social Work / Child Life or RN join PSWRClerk or Social Work / Child Life or RN join PSWR

Conference Room DiscussionConference Room Discussion

• Review purpose of PSWRsReview purpose of PSWRs

• Open-ended general questions and discussionOpen-ended general questions and discussionwith 5 individuals chosen from clinical areawith 5 individuals chosen from clinical area

• Discussion / information is reported without Discussion / information is reported without identifiers to an individualidentifiers to an individual

General Questions for PSWR ParticipantsGeneral Questions for PSWR Participants

• In your last few shifts, have you experienced any In your last few shifts, have you experienced any

“near misses” that almost caused patient harm but “near misses” that almost caused patient harm but

were avoided? Have you noticed any incidents that were avoided? Have you noticed any incidents that

actually did result in patient harm? (please describe)actually did result in patient harm? (please describe)

• What should be done to encourage reporting of What should be done to encourage reporting of

““near misses events?”near misses events?”

General Questions General Questions for PSWR Participantsfor PSWR Participants

• Based on discussion of near misses, please provide Based on discussion of near misses, please provide

suggestions on how we could improve the safety of suggestions on how we could improve the safety of

patientspatients in our ED.in our ED.

• Have you developed any personal practices to help Have you developed any personal practices to help you prevent making errors in the ED?you prevent making errors in the ED?

• If you could fix one thing in the ED to make it a safer If you could fix one thing in the ED to make it a safer place for patients, what would it be?place for patients, what would it be?

PSWR Follow-upPSWR Follow-up

• Multidisciplinary team meets twice per month Multidisciplinary team meets twice per month

- Reviews latest PSWR data and IR’s- Reviews latest PSWR data and IR’s

- Follow-up report generated regarding issues - Follow-up report generated regarding issues observed, resolution, and who is accountableobserved, resolution, and who is accountable

• Dissemination of ideas / results to staffDissemination of ideas / results to staff

Our ExperienceOur Experience(First 9 Months)(First 9 Months)

• 20 20 Unit-basedUnit-based PSWR PSWR

• 30% on weekends,30% on weekends,65% on evenings / overnights65% on evenings / overnights

• 99 staff members participated99 staff members participated

Lessons LearnedLessons Learned

20% aborted and rescheduled20% aborted and rescheduled

Orientation and Communication are EssentialOrientation and Communication are Essential

• General – each group of constituentsGeneral – each group of constituents

• Individual – leaders prior to PSWRIndividual – leaders prior to PSWR

Discoveries and ActionsDiscoveries and Actions

• Numerous issues identifiedNumerous issues identified

• Action items involved:Action items involved:

- Multiple services- Multiple services

- Education of staff- Education of staff

- New policies and procedures- New policies and procedures

- Occasional “quick fixes”- Occasional “quick fixes”

Patient / Family Communication ToolPatient / Family Communication Tool

Systems Issue:Systems Issue:

Families could not identify staff rolesFamilies could not identify staff roles

Solutions (unit-based):Solutions (unit-based):Dry erase board in each room Dry erase board in each room with providers’ nameswith providers’ names

Bedside report and roundingBedside report and rounding

Hand-Washing ToolHand-Washing Tool

Systems Issue:Systems Issue:

Lack of alcohol hand-rub in each roomLack of alcohol hand-rub in each room

Solutions (multiple services):Solutions (multiple services): Environmental ServicesEnvironmental Services

Environmental Health and SafetyEnvironmental Health and Safety

PurchasingPurchasing

Monitoring and AlarmsMonitoring and AlarmsSystems Issue:Systems Issue:

No standard for initiating CR mentoringNo standard for initiating CR mentoring

Lack of age-appropriate alarm parameterLack of age-appropriate alarm parameter

Inaudible alarmsInaudible alarms

Solutions (unit-based and hospital-wide):Solutions (unit-based and hospital-wide):

Standards establishedStandards established

Mandatory education on age-based parametersMandatory education on age-based parameters

Biomedical engineering to increase alarm volumesBiomedical engineering to increase alarm volumes

Patient Safety DiscussionPatient Safety DiscussionSystems Issue:Systems Issue:

Staff unclear as to when or why to complete Staff unclear as to when or why to complete

incident reports; “tattling” vs. identification incident reports; “tattling” vs. identification and preventionand prevention

Solutions:Solutions:

Staff communication (emails, meetings)Staff communication (emails, meetings)

Emphasis on systems issues and solutionsEmphasis on systems issues and solutions

Praising near-miss reportingPraising near-miss reporting

Feedback on PSWR / IR’s monthlyFeedback on PSWR / IR’s monthly

Medication “Near-Miss” Incident ReportsMedication “Near-Miss” Incident Reports

0.58 0.60

0.85

0

0.2

0.4

0.6

0.8

1

FY04 FY05 FY06

Rate per 1000 Rate per 1000

ED PatientsED Patients

Conclusions: Conclusions: Unit-basedUnit-based PSWR PSWR

• Inspire staff to participate in making their Inspire staff to participate in making their unit safeunit safe

• Identify multiple issues not reported Identify multiple issues not reported by usual practiceby usual practice

• Lead to multiple systems improvements Lead to multiple systems improvements to improve patient safetyto improve patient safety

Further InformationFurther Information

Creating Unit-based Patient Safety Walkrounds in a Creating Unit-based Patient Safety Walkrounds in a

Pediatric Emergency DepartmentPediatric Emergency Department

Kathy N. Shaw, MD, MSCEKathy N. Shaw, MD, MSCE

Jane M. Lavelle, MDJane M. Lavelle, MD

Kelly Crescenzo, RN, BSN, CENKelly Crescenzo, RN, BSN, CEN

Jacqueline Noll, RN, BSN, CENJacqueline Noll, RN, BSN, CEN

Nancy Bonalumi, RN, MS, CENNancy Bonalumi, RN, MS, CEN

Jill Baren, MDJill Baren, MD

Clin Pediatr Emerg MedClin Pediatr Emerg Med, December, 2006, Elsevier, Inc., December, 2006, Elsevier, Inc.