By Bridget Norton, M.D., MBA, Chief Quality & Safety Officer
Case Review Learning Moments September 2020
Cardiac Arrest Prevention (CAP) Program It is appropriate for a DNR patient to be enrolled in CAP or other programs designed to improve patient care. Despite having a DNR order, the patient should still receive our best care. Preventing a code event will allow the patient the opportunity to go home, transfer to a lower level of care or pass away peacefully with family rather than during a code event when family may not be present. (CAP Code/Cardiac Event Review)
Interpreting Services When using an interpreter for a patient/family from Sudan, it is important that we request the interpreter be from the same country (North Sudan versus South Sudan) as the family for cultural/political reasons. If the interpreter is not from the same country, the family may refuse to speak with them. (ECMO Case Review)
Documentation of COVID-19 in the Problem List We are testing all inpatients for SARS-CoV-2 on admission but some patients are admitted with a test that has already been done at an outside facility. It is vital that patients who have a positive test, regardless of whether it was done at Children’s, and regardless of their inpatient unit, have “COVID-19 positive” added to their problem list. This documentation is our clinical responsibility. Appropriate documentation helps ensure good communication and proper isolation to protect our staff, as well as other patients. The adjustments that were made to the pandemic code policy to allow a different response to patients who are known negative also relies on having this accurately documented. If you have any questions, please feel free to email me (BNorton@ChildrensOmaha.org) or Incident Command.
A summary of learning moments from various case review meetings has been created. In this Case Review Learning memo, read about cultural beliefs and traditions, diagnosing without bias, meningitis identification and new pathways. If anyone has learning moments to share from your area case reviews, please email them to Erin Scrivner or Bridget Norton, M.D.
Yes, there are non-COVID-19 patients still out there!
By Bridget M. Norton, M.D., MBA
We would like to provide an update on our organizational sepsis project and the Improving Pediatric Sepsis Outcomes (IPSO) Collaborative. It may not seem like much work is going on outside of COVID-19, but despite many competing priorities, our organizational sepsis work has continued. This work is being led by the Sepsis Steering Committee, which includes Amber Marquiss, Kim Peterson, Carol Beare, Meghan Spencer and me. We have not been able to meet in person because of current restrictions, but it has forced us to move out of our comfort zones and further embrace technology. Recognizing that this may be our new normal, we have decided that we will be conducting nearly all sepsis work virtually, through the use of WebEx, recorded WebEx sessions and email. Additionally, our area-based work groups will use our new Projectplace platform.
Work completed thus far:
Sepsis kick-off meetings were held March 2 and 3.
Subject matter experts helped draft current state process flows for each care area.
Current state process flows were sent out to area-based work groups for evaluation and feedback.
IPSO Collaborative Baseline Data Mapping used IPSO definitions and guidelines
Continue IPSO Baseline Data Mapping and evaluation of the quality of the data with our data/analytics work group.
Finalize current state process flows.
Begin order set development.
Begin designing future state processes for the HUDDLE.
Forty-two children were saved from
preventable harm thanks to Children’s hospital-acquired conditions (HAC) work
in 2019. HACs are preventable harm events that patients experience while in the
hospital. These children were saved from preventable harm, representing a 31
percent decrease from 2018.
The K card initiative to reduce HACs
was a major project started last year. We have reached a milestone of more than
1,000 K cards completed.
Children’s has been recognized as ‘highly engaged’ by the
Children’s Hospital Association’s Patient Safety Organization (PSO). The PSO
has 63 participating children’s hospitals and is designed by pediatric safety
leaders to eliminate preventable serious patient harm. Through this work,
trends in patient safety events are shared nationally and the PSO works
together with hospitals to develop safety alerts to mitigate these risks.
Children’s participation includes:
huddles with our 62 peers – similar to Children’s daily safety brief – in which
hospitals share urgent safety concerns.
PSO monthly safe
tables – rotating hospitals share serious safety events and their actions for
Safety alerts –
when trends are identified, a safety alert is created for all hospitals to
review, assess the risk and create action plans. Two recent samples are
When an Eye on Safety event is reported in RLDatix or communicated to Performance Improvement (PI) or Administration by area leadership, a cause analysis is considered. Cause analysis focuses on the process and system deviations that need to be improved in order for all of us to perform at our best and provide the highest quality care for our patients.
The kind of cause analysis to conduct is the first question. The level of harm to the patient and the potential for system-wide spread of the issue drive the determination of whether the event is reported as Apparent Cause Analysis (ACA), Common Cause Analysis (CCA) or Root Cause Analysis (RCA).
Dr. Lucian Leape, professor from the Harvard School of Public Health, said, “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” As an organization, we have committed to moving away from the punitive, reactive type of culture described by Dr. Leape, and toward being proactive, focusing on prevention by embracing what is known as Just Culture.
What is a Just Culture? The term Just Culture refers to a values-supportive system of shared accountability where organizations are accountable for the systems they have designed and for responding to the behaviors of their employees in a fair and just manner. Employees, in turn, are accountable for the quality of their choices and for reporting both errors and system vulnerabilities.
— Outcome Engenuity, LLC. 2013
In a Just Culture:
Organizational leaders ensure the design of safe systems (equipment, policies, software, etc.). If the system is flawed or broken it is leadership’s responsibility to fix it.
Providers & employees make behavioral choices, determining how they act and react within these systems. They are held accountable for the quality of their choices.
At the core of Just Culture is a process for allocating responsibility for events – that is, what is caused by the system, and what is caused by the human component.
When events occur, leaders will be asking what, why, and how it happened and there will be an investigation to determine any areas where the system may have broken down, and assess the risk of future events.
As physicians, we must be empowered both as leaders and members of the organization to report events that have already occurred, as well as areas of risk for future events. We must also be supportive of our Just Culture and the other leaders in the organization by focusing on the what, why and how of adverse events, helping to identify opportunities to improve the safety of the system and learn from these events to prevent them from happening in the future.
All providers should have received an email from Chris Maloney, M.D., Ph.D., with instructions on how to sign up in Cornerstone to take the Just Culture class. Physician and APP courses will be offered in November. This course is required for all hospital and Children’s Specialty Physicians staff, but we highly recommend that all members of the medical staff participate, as you are part of the culture of Children’s Hospital & Medical Center. If you have any questions please feel free to reach out to Dr. Maloney, Kim Peterson or me, Bridget Norton, M.D.
On Tuesday, Aug. 27, Quantros retired and RLDatix went live as Children’s new system for reporting adverse events, now called Eye on Safety (EOS) reports. RLDatix is an all-inclusive safety, quality and risk-management software that facilitates the management of adverse events from start to finish. It was designed for health care organizations striving to revolutionize how their patients experience care. The comprehensive, web-based software provides a unified platform to document, manage and report any type of adverse safety event, complaint and compliance issue.
RLDatix offers features such as icons to simplify event type
selection, a file submission tracker to allow submitters the ability to view
the status of their reported events, an Epic interface that links the patient’s
admission-discharge-transfer (ADT) and medication information and optimized
reports for data analytics. The new system is accessible from desktops,
Children’s intranet or through Epic.
A new Clinical Care and Management icon has been created
specifically for physicians to enter information about any event that occurs
concerning the clinical care and management of our patients. Unlike the rest of the EOS reports, these
events will be reviewed by the medical director(s) of the area or areas
involved in the event if providers are involved. If the issues are
nursing-related, they will be reviewed by the appropriate nursing leader.
When entering the event, select provider or non-provider, then
select all of the clinical areas involved. This determines which medical
directors review the event. This new icon does not take the place of our
existing professional practice evaluation committee (PPEC) screening process
and, if appropriate, medical directors will refer events for PPEC screening. The
video below demonstrates entering an EOS report by clicking on the Clinical
Care and Management icon.
Reporting events in RLDatix will help us reduce harm and leverage
lessons learned across our organization. If you have any questions, please feel
free to email Bridget
Norton, M.D. Children’s chief Quality & Safety officer, or if you have any
other questions or feedback about the system, please email email@example.com.
Bridget M. Norton, M.D., MBA, Children’s Chief Quality & Safety Officer
As members of the Solutions for
Patient Safety (SPS), a hospital engagement network collaborative of over 135
pediatric hospitals, we are currently focusing some of our safety efforts on 12
hospital-acquired conditions (HACs) that have been identified as preventable
harm events that have significant implications for our patients. For example, published
data estimates that 20 percent of unplanned extubations result in an arrest.A
2013 Joint Commission article showed that out of 80,000 ICU patients with a
central line infection, 30,000 (37.5 percent) died, and venous thromboembolism
can lead to post-thrombotic syndrome which can affect a patient for life. Since
its development, it is estimated that the work of the SPS hospitals has saved
11,000 children from harm and saved over $182 million in health care costs.
Children’s has been a member since 2012, and our ongoing efforts are championed
by the HAC Oversight Committee and its subgroups.
Many providers feel that HAC work is largely in the hands of the nurses or other staff, and physicians don’t have a direct role in preventing them; however, there are actually many things providers can do to support this work. The table below gives some examples of ways we can make an impact. Not all of them will apply to all areas, but no matter where we work, we can all make a difference by supporting the nursing and ancillary staff in their work, answering questions and participating in cause analyses and debriefs when events do occur.
Providers and HACs — What Can You Do?
Adverse Drug Events
Utilize CPOE and verify accuracy every time. Only use verbal orders in emergent situations.
Remove Foleys within 24 hours if not clinically indicated.
Central Line-Associated Blood Stream Infections (CLABSI)
Follow the insertion bundle. Daily review of the function, utilization and necessity of the line (can it come out?) Look at the dressing – is it clean/dry/occlusive?
Does your patient need a specialty bed? Remember that high-risk patients can still be repositioned with a slight “tilt” or shift in weight.
Surgical Site Infections (SSI)
Ensure appropriate antibiotic timing and re-dosing. Compliance with bundle & OR sterility policies and procedures.
Review extubation readiness with RN/RT/team. Extubate at the best time for the patient.
Venous Thromboembolism (VTE)
For high-risk patients, consider anticoagulation. Accurately document patients with VTE. Remember, central lines increase the incidence of VTEs.
Hand hygiene is still the #1 proven way to prevent infection. Be cognizant of recontamination of your hands within the room after initial hand hygiene has been completed. Advocate for objects, such as stuffed animals, to be kept out of patient beds.
For more information about our work
with SPS or “K cards,” our newest initiative designed to ensure bundle
compliance of 90 percent or greater, click here to read more or
feel free to contact me via email at Bridget Norton, M.D., with questions
By Bridget M. Norton, MD, MBA, Chief Quality & Safety Officer
Starting Aug. 1, we will feature a new recurring article in The Pulse discussing different topics related to Children’s ongoing quality and safety work and detailing why it is relevant for physicians. These articles will give a better understanding of the role of the Chief Quality & Safety Officer, while providing further information on the different quality and safety projects underway and more. Please email me with suggestions for topics you would like to hear more about.
In addition, you will see more articles in The Pulse and other publications discussing the latest information on the system level action items perpetually being generated by the work done in RCAs, case reviews, debriefs and variance reviews. Our goal is to make you aware of the systems issues being identified, as well as how they are being addressed, in order to share the lessons learned and improve the care we are providing to our patients.
If there are other topics you would like to hear more about, please feel free to email me with your ideas and suggestions and keep reading The Pulse for ongoing quality and safety messaging .