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AEs and ADEs occur frequently in the PICU setting. These data provide areas of focus for evidence-based prevention strategies to decrease the substantial risk to this vulnerable pediatric population.

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BACKGROUND AND OBJECTIVE: Patient handoffs in health care require transfer of information, responsibility, and authority between providers. Suboptimal patient handoffs pose a serious safety risk. Studies demonstrating the impact of improved patient handoffs on care failures are lacking. The primary objective of this study was to evaluate the effect of a multihospital collaborative designed to decrease handoff-related care failures.METHODS: Twenty-three children' s hospitals participated in a quality improvement collaborative aimed at reducing handoff-related care failures. The improvement was guided by evidence-based recommendations regarding handoff intent and content, standardized handoff tools/methods, and clear transition of responsibility. Hospitals tailored handoff elements to locally important handoff types. Handoff-related care failures were compared between baseline and 3 intervention periods. Secondary outcomes measured compliance to specific change package elements and balancing measure of staff satisfaction. RESULTS:Twenty-three children' s hospitals evaluated 7864 handoffs over the 12-month study period. Handoff-related care failures decreased from baseline (25.8%) to the final intervention period (7.9%) (P , .05). Significant improvement was observed in every handoff type studied. Compliance to change package elements improved (achieving a common understanding about the patient from 86% to 96% [P , .05]; clear transition of responsibility from 92% to 96% [P , .05]; and minimized interruptions and distractions from 84% to 90% [P , .05]) as did overall satisfaction with the handoff (from 55% to 70% [P , .05]).CONCLUSIONS: Implementation of a standardized evidence-based handoff process across 23 children' s hospitals resulted in a significant decrease in handoff-related care failures, observed over all handoff types. Compliance to critical components of the handoff process improved, as did provider satisfaction. Pediatrics 2014;134: e572-e579 AUTHORS:

BackgroundThe area of healthcare quality and patient safety is starting to use health information technology to prevent reportable events, identify them before they become issues, and act on events that are thought to be unavoidable. As healthcare organizations begin to explore the use of health information technology in this realm, it is often unclear where fiscal and human efforts should be focused.ObjectiveThe purpose of this study was to provide a foundation for understanding where to focus health information technology fiscal and human resources as well as expectations for the use of health information technology in healthcare quality and patient safety.MethodsA literature review was conducted to identify peer-reviewed publications reporting on the actual use of health information technology in healthcare quality and patient safety. Inductive thematic analysis with open coding was used to categorize a total of 41 studies. Three pre-set categories were used: prevention, identification, and action. Three additional categories were formed through coding: challenges, outcomes, and location.ResultsThis study identifies five main categories across seven study settings. A majority of the studies used health IT for identification and prevention of healthcare quality and patient safety issues. In this realm, alerts, clinical decision support, and customized health IT solutions were most often implemented. Implementation, interface design, and culture were most often noted as challenges.ConclusionsThis study provides valuable information as organizations determine where they stand to get the most “bang for their buck” relative to health IT for quality and patient safety. Knowing what implementations are being effectivity used by other organizations helps with fiscal and human resource planning as well as managing expectations relative to cost, scope, and outcomes. The findings from this scan of the literature suggest that having organizational champion leaders that can shepherd implementation, impact culture, and bridge knowledge with developers would be a valuable resource allocation to consider.

A complex process, such as patient deterioration, requires sufficient time and effort to achieve improved outcomes and create a deeply embedded culture of patient safety. The collaborative model can accelerate improvements achieved by individual institutions.

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