OBJECTIVES: Event debriefing has established benefit, but its adoption is poorly characterized among pediatric ward providers. To improve patient safety, our hospital restructured its debriefing process for ward deterioration events culminating in ICU transfer. The aim of this study was to describe this process’ implementation. METHODS: In the restructured process, multidisciplinary ward providers are expected to debrief all ICU transfers. We conducted a multimethod analysis using facilitative guides completed by debriefing participants. Monthly debriefing completion served as an adoption metric. RESULTS: Between March 2019 and February 2020, providers across 9 wards performed debriefing for 134 of 312 PICU transfers (43%). Bedside nurses participated most frequently (117 debriefings [87%]). There was no significant difference in debriefing by unit, acuity, season, or nurse staffing. Compared with units fully staffed by rotational frontline clinicians (FLCs; eg, resident physicians), units with dedicated FLCs whose responsibilities are primarily limited to that unit (eg, oncology hospitalists) completed significantly more monthly debriefings (average [SD] 57% [30%] vs 33% [28%] of PICU transfers; P = .004). FLC participation was also higher on these units (50% of debriefings [37%] vs 24% [37%]; P = .014). Through qualitative analysis, we identified distinct debriefing themes, with teaming activities such as communication cited most often. CONCLUSIONS: Implementation of a multidisciplinary debriefing process for ward deterioration events culminating in ICU transfer was associated with differential adoption across providers and FLC staffing models but not acuity or nurse staffing. Teaming activities were a debriefing priority. Future study will assess patient safety outcomes.
Repeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. We had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, we committed ourselves to trying something genuinely different—even perhaps disruptive—that might actually shift our stagnant metrics. Our novel, multifaceted program, implemented over a two-year period, yielded a 13% increase in staff rating scores that we have been able to sustain over the subsequent two-year period. The design and rollout of our program was neither simple nor smooth, but it has taught us valuable lessons about realistic, operational implementation of principles of psychological safety in a large and complex clinical organization. In this paper, we describe our program and the lessons learned in the journey from idea inception to post-implementation.
H ospitals and health care systems facing capacity strain due to changes in patient volume, patient acuity, or resource allocation may see increases in safety events as teams adapt to new stressors. Organizations need to establish and sustain cultures that support timely and honest reporting of safety events. Nurses are pivotal in promoting patient safety, as they make up the largest health care discipline. Research demonstrates that improved nursing resources in terms of work environment, staffing, and education can be associated with improvement in quality and patient safety outcomes. 1 PROBLEM Starting in 2008, nursing leadership at a large quaternary care, pediatric medical center recognized that expansion in patient census and acuity was posing challenges for safety management
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