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.

Reducing Wait Time in a High-volume Pediatric Neuro-oncology Clinic by Optimizing Process Flow: A Quality Improvement Project.

Introduction: Hospital wait time (WT) influences healthcare quality and patient satisfaction. Long WTs are distressful for patients and considered substandard healthcare delivery. Pediatric hematology/oncology patients with complex medical conditions frequently need multiple appointments in a day, making their scheduling very challenging.

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.

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.

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.

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.

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.

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.

Psychometric Properties of Korean Version of the Second Victim Experience and Support Tool (K-SVEST).

Objectives: "Second victims" are defined as healthcare professionals whose wellness is influenced by adverse clinical events. The Second Victim Experience and Support Tool (SVEST) was used to measure the second-victim experience and quality of support resources. Although the reliability and validity of the original SVEST have been validated, those for the Korean tool have not been validated.

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.

A Multilevel Analysis of U.S. Hospital Patient Safety Culture Relationships With Perceptions of Voluntary Event Reporting.

Objectives: Patient safety events offer opportunities to improve patient care, but, unfortunately, events often go unreported. Although some barriers to event reporting can be reduced with electronic reporting systems, insight on organizational and cultural factors that influence reporting frequency may help hospitals increase reporting rates and improve patient safety. The purpose of this study was to evaluate the associations between dimensions of patient safety culture and perceived reporting practices of safety events of varying severity.

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.

Patient Safety Culture and the Second Victim Phenomenon: Connecting Culture to Staff Distress in Nurses.

Background: Second victim experiences can affect the wellbeing of health care providers and compromise patient safety. Many factors associated with improved coping after patient safety event involvement are also components of a strong patient safety culture, so that supportive patient safety cultures may reduce second victim-related trauma. A cross-sectional survey study was conducted to assess the influence of patient safety culture on second victim-related distress.

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.

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.

The Second Victim Experience and Support Tool: Validation of an Organizational Resource for Assessing Second Victim Effects and the Quality of Support Resources.

Objectives: Medical errors and unanticipated negative patient outcomes can damage the well-being of health care providers. These affected individuals, referred to as "second victims," can experience various psychological and physical symptoms. Support resources provided by health care organizations to prevent and reduce second victim-related harm are often inadequate.

Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.

Objective: To investigate the use of a trigger tool for the detection of adverse drug events (ADE) in a pediatric hospital specializing in oncology, hematology, and other catastrophic diseases.

Study Design: A medication-based trigger tool package analyzed electronic health records from February 2009 to February 2013. Chart review determined whether an ADE precipitated the trigger.

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.