BACKGROUND: An estimated 10% of Americans experience a diagnostic error annually, yet little is known about pediatric diagnostic errors. Physician reporting is a promising method for identifying diagnostic errors. However, our pediatric hospital medicine (PHM) division had only 1 diagnostic-related safety report in the preceding 4 years. We aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. METHODS: Our improvement team used the Model for Improvement, targeting the PHM service. To promote a safe reporting culture, we used the term diagnostic learning opportunity (DLO) rather than diagnostic error, defined as a “potential opportunity to make a better or more timely diagnosis.” We developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. The outcome measure, the number of DLO reports per 100 patient admissions, was tracked on an annotated control chart to assess the effect of our interventions over time. We evaluated DLOs using a formal 2-reviewer process. RESULTS: Over the course of 13 weeks, there was an increase in the number of reports filed from 0 to 1.6 per 100 patient admissions, which met special cause variation, and was subsequently sustained. Most events (66%) were true diagnostic errors and were found to be multifactorial after formal review. CONCLUSIONS: We used quality improvement methodology, focusing on psychological safety, to increase physician reporting of DLOs. This growing data set has generated nuanced learnings that will guide future improvement work.
Background Although M. pneumoniae (M. pneumoniae) infections have been associated with various extrapulmonary manifestations, there have been very few documented cases of thrombotic events in pediatrics, and none to our knowledge with such extensive involvement as the patient described here. We aim to contribute to the urgency of discovering the mechanism of the coagulopathy associated with M. pneumoniae infections. Case presentation This 10-year-old boy was admitted after 2 weeks of fever, sore throat, worsening cough, and progressive neck and back pain. During hospitalization, he developed clots in several different organs: bilateral pulmonary emboli, cardiac vegetations, multiple splenic infarcts, and deep venous thromboses in three of four extremities. He was treated with long-term antibiotics and anticoagulation, and fully recovered. Conclusions This is the first case known to us of a child with an extensive number of thrombotic events in multiple anatomic sites associated with M. pneumoniae infection. The mechanism by which M. pneumoniae infection is related to thrombotic events is not fully understood, but there is evidence that the interplay between the coagulation pathways and the complement cascade may be significant. This patient underwent extensive investigation, and was found to have significant coagulopathy, but minimal complement abnormalities. By better understanding the mechanisms involved in complications of M. pneumoniae infection, the clinician can more effectively investigate the progression of this disease saving time, money, morbidity, and mortality.
BACKGROUND: Febrile infants aged 0 to 60 days are often hospitalized for a 36-to-48 hour observation period to rule out invasive bacterial infections (IBI). Evidence suggests that monitoring blood and cerebrospinal fluid (CSF) cultures for 24 hours may be appropriate for most infants. We aimed to decrease the average culture observation time (COT) from 38 to 30 hours among hospitalized infants 0 to 60 days old over 12 months. METHODS: This quality improvement initiative occurred at a large children’s hospital, in conjunction with development of a multidisciplinary evidence-based guideline for the management of febrile infants. We included infants aged 0 to 60 days admitted with fever without a clear infectious source. We excluded infants who had positive blood, urine, or CSF cultures within 24 hours of incubation and infants who were hospitalized for other indications (eg, bronchiolitis). Interventions included guideline dissemination, education regarding laboratory monitoring practices, standardized order sets, and near-time identification of failures. Our primary outcome was COT, defined as time between initiation of culture incubation and hospital discharge in hours. Interventions were tracked on an annotated statistical process control chart. Our balancing measure was identification of IBI after hospital discharge. RESULTS: In our cohort of 184 infants aged 0 to 60 days, average COT decreased from 38 hours to 32 hours after structured guideline dissemination and order-set standardization; this decrease was sustained over 17 months. IBI was not identified in any patients after discharge. CONCLUSIONS: Implementation of an evidence-based guideline through education, transparency of laboratory procedures, creation of standardized order sets, and near-time feedback was associated with shorter COT for febrile infants aged 0 to 60 days.
From 1999 through 2010, a team of scientists and engineers systematically reviewed approximately eight million classified and unclassified documents at Los Alamos National Laboratory (LANL) that describe historical off-site releases of radionuclides and chemicals in order to determine the extent to which a full-scale dose reconstruction for releases is warranted and/or feasible. As a part of this effort, a relative ranking of historical airborne and waterborne radionuclide releases from LANL was established using priority index (PI) values that were calculated from estimated annual quantities released and the maximum allowable effluent concentrations according to The U.S. Nuclear Regulatory Commission (USNRC). Chemical releases were ranked based on annual usage estimates and U.S. Environmental Protection Agency (USEPA) toxicity values. PI results for airborne radionuclides indicate that early plutonium operations were of most concern between 1948 and 1961, in 1967, and again from 1970 through 1973. Airborne releases of uranium were found to be of most interest for 1968, from 1974 through 1978, and again in 1996. Mixed fission products yielded the highest PI value for 1969. Mixed activation product releases yielded the highest PI values from 1979 to 1995. For waterborne releases, results indicate that plutonium is of most concern for all years evaluated with the exception of 1956 when (90)Sr yielded the highest PI value. The prioritization of chemical releases indicate that four of the top five ranked chemicals were organic solvents that were commonly used in chemical processing and for cleaning. Trichloroethylene ranked highest, indicating highest relative potential for health effects, for both cancer and non-cancer effects. Documents also indicate that beryllium was used in significant quantities, which could have lead to residential exposures exceeding established environmental and occupational exposure limits, and warrants further consideration. In part because of the close proximity of residents to LANL, further study of historical LANL releases and the potential impact to public health is recommended for those materials with the largest priority index values; namely, plutonium, uranium, and selected chemicals.
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