Safety Rounds in Ambulatory and Inpatient Settings Wednesday, October 25, 2006 12:00 – 1:00 p.m. EDT

1. Safety Rounds in Ambulatory and Inpatient SettingsWednesday, October 25, 200612:00 – 1:00 p.m. EDT

2. Moderator: Uma Kotagal, MD, MBBS, MSCE, FAAP Vice President for Quality and Transformation Director, Center for Health Policy & Clinical Effectiveness Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

3. This activity was funded through an educational grant from the Physicians’ Foundation for Health Systems Excellence.

4. Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities Grid The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional performance of pediatric healthcare professionals by providing high quality, relevant, accessible and cost-effective educational experiences. The AAP CME program provides activities to meet the participants’ identified education needs and to support their lifelong learning towards a goal of improving care for children and families (AAP CME Program Mission Statement, August 2004). The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest. All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity. The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is committed to providing learners with commercially unbiased CME activities.

5. DISCLOSURES

6. DISCLOSURES

7. DISCLOSURES

8. CME CREDIT The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAP designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This activity is acceptable for up to 1.0 AAP credit. This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

9. OTHER CREDIT This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 0.0 contain pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2633. The American Academy of Physician Assistants accepts AMA PRA Category 1 Credit(s)TM from organizations accredited by the ACCME .

10. Featured Speaker: Kathy N. Shaw, MD, MSCE, FAAP Chief, Division of Emergency Medicine The Children’s Hospital of Philadelphia Philadelphia, Pennsylvania

11. OBJECTIVES Upon completion of this activity, participants will be able to: • Describe the process and explain the rationale for senior leader-driven Safety Rounds in ambulatory and inpatient settings. • List the types of safety issues identified on Safety Rounds, and distinguish similarities and differences between safety issues in ambulatory and inpatient settings. • Select and apply at least one strategy to ensure issues identified on Safety Rounds are efficiently and effectively discussed with all appropriate individuals and improvements are implemented.

12. The Children’s Hospital of Philadelphia Emergency Department Unit-Based Patient Safety WalkRounds Kathy N. Shaw, M.D., M.S.C.E. Chief, Division of Emergency Medicine Professor of Pediatrics at CHOP University of Pennsylvania School of Medicine The Nicholas Crognale Endowed Chair in Pediatric Emergency Medicine

13. Purpose of WalkRounds • Mechanism for communicating with staff about safety issues • Signal staff on the front lines that there is commitment to a culture of safety • Foster open communication and a blame-free environment • Gather ideas to take action to make a safer work place

14. Unit-based PSWR • Stakeholders vs. visitors • Ubiquitous vs. sporadic • Rapid response and dissemination of information vs. not . . .

15. When: Unit-based PSWR • Minimum of 2 times / month • All days of the week • All times of the day

16. Participants: Unit-based PSWR • Team leaders: • PEM attending / 2 RNs • Staff Participants: • Resident • ED nurse • Clerical staff • Social worker or Child Life therapist • Respiratory therapist or Radiology tech • Environmental Services or ED tech

17. Where: Unit-based PSWR • CQI in patient care area of the ED (15-20 min) • Group meeting in the ED conference room (15-20 min)

18. Tool Kit: Unit-based PSWR • Step by Step Guide to Conducting PSWR • Quality Improvement Indicator Tools • General Questions for Group Discussion

19. ED Based CQI Activities • 4 team members complete CQI tools in ED • Clinical observations • Interviews with staff / parents • Review of chart, electronic tracking and ordering system

20. Quality Improvement Tools 1. Accuracy of weight and allergy documentation RN or tech joins PSWR • Appropriateness of patient monitoring and alarm parameters /central monitoring RN joins PSWR 3. Reasons for prolonged ED length of stay> 3 hrs Resident joins PSWR

21. Quality Improvement Tools • Accuracy of medication orders, administration, and documentation ED RN or MD joins PSWR 5. Compliance with hand washing RN joins PSWR; person from Environmental Services identified to complete room check part of QI 6. Patient / family communication (directed at patient/caregiver) Clerk or Social Work / Child Life or RN join PSWR

23. Conference Room Discussion • Review purpose of PSWRs • Open-ended general questions and discussion with 5 individuals chosen from clinical area • Discussion / information is reported without identifiers to an individual

24. General Questions for PSWR Participants • In your last few shifts, have you experienced any “near misses” that almost caused patient harm but were avoided? Have you noticed any incidents that actually did result in patient harm? (please describe) • What should be done to encourage reporting of “near misses events?”

25. General Questions for PSWR Participants • Based on discussion of near misses, please provide suggestions on how we could improve the safety of patients in our ED. • Have you developed any personal practices to help you prevent making errors in the ED? • If you could fix one thing in the ED to make it a safer place for patients, what would it be?

26. PSWR Follow-up • Multidisciplinary team meets twice per month - Reviews latest PSWR data and IR’s - Follow-up report generated regarding issues observed, resolution, and who is accountable • Dissemination of ideas / results to staff

27. Our Experience(First 9 Months) • 20 Unit-based PSWR • 30% on weekends, 65% on evenings / overnights • 99 staff members participated

28. Lessons Learned 20% aborted and rescheduled Orientation and Communication are Essential • General – each group of constituents • Individual – leaders prior to PSWR

29. Discoveries and Actions • Numerous issues identified • Action items involved: - Multiple services - Education of staff - New policies and procedures - Occasional “quick fixes”

30. Patient / Family Communication Tool Systems Issue: Families could not identify staff roles Solutions (unit-based): Dry erase board in each room with providers’ names Bedside report and rounding

31. Hand-Washing Tool Systems Issue: Lack of alcohol hand-rub in each room Solutions (multiple services): Environmental Services Environmental Health and Safety Purchasing

32. Monitoring and Alarms Systems Issue: No standard for initiating CR mentoring Lack of age-appropriate alarm parameter Inaudible alarms Solutions (unit-based and hospital-wide): Standards established Mandatory education on age-based parameters Biomedical engineering to increase alarm volumes

33. Patient Safety Discussion Systems Issue: Staff unclear as to when or why to complete incident reports; “tattling” vs. identification and prevention Solutions: Staff communication (emails, meetings) Emphasis on systems issues and solutions Praising near-miss reporting Feedback on PSWR / IR’s monthly

34. Medication “Near-Miss” Incident Reports Rate per 1000 ED Patients

35. Conclusions: Unit-based PSWR • Inspire staff to participate in making their unit safe • Identify multiple issues not reported by usual practice • Lead to multiple systems improvements to improve patient safety

36. Further Information Creating Unit-based Patient Safety Walkrounds in a Pediatric Emergency Department Kathy N. Shaw, MD, MSCE Jane M. Lavelle, MD Kelly Crescenzo, RN, BSN, CEN Jacqueline Noll, RN, BSN, CEN Nancy Bonalumi, RN, MS, CEN Jill Baren, MD Clin Pediatr Emerg Med, December, 2006, Elsevier, Inc.