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Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

American Academy of Pediatrics
Quality Report

Improving Situation Awareness to Reduce Unrecognized Clinical Deterioration and Serious Safety Events

Patrick W. Brady, Stephen Muething, Uma Kotagal, Marshall Ashby, Regan Gallagher, Dawn Hall, Marty Goodfriend, Christine White, Tracey M. Bracke, Victoria DeCastro, Maria Geiser, Jodi Simon, Karen M. Tucker, Jason Olivea, Patrick H. Conway and Derek S. Wheeler
Pediatrics January 2013, 131 (1) e298-e308; DOI: https://doi.org/10.1542/peds.2012-1364
Patrick W. Brady
Divisions of aHospital Medicine,
bThe James M. Anderson Center for Health Systems Excellence,
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Stephen Muething
Divisions of aHospital Medicine,
bThe James M. Anderson Center for Health Systems Excellence,
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Uma Kotagal
bThe James M. Anderson Center for Health Systems Excellence,
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Marshall Ashby
bThe James M. Anderson Center for Health Systems Excellence,
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Regan Gallagher
eDepartment of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
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Dawn Hall
eDepartment of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
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Marty Goodfriend
dFamily Relations,
eDepartment of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
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Christine White
Divisions of aHospital Medicine,
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Tracey M. Bracke
bThe James M. Anderson Center for Health Systems Excellence,
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Victoria DeCastro
eDepartment of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
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Maria Geiser
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Jodi Simon
fDivision of Quality Services, Akron Children’s Hospital, Akron, Ohio; and
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Karen M. Tucker
eDepartment of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
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Jason Olivea
bThe James M. Anderson Center for Health Systems Excellence,
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Patrick H. Conway
Divisions of aHospital Medicine,
gCenters for Medicare and Medicaid Services, Office of Clinical Standards and Quality, Baltimore, Maryland
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Derek S. Wheeler
bThe James M. Anderson Center for Health Systems Excellence,
cCritical Care Medicine, Department of Pediatrics, and
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Abstract

BACKGROUND AND OBJECTIVE: Failure to recognize and treat clinical deterioration remains a source of serious preventable harm for hospitalized patients. We designed a system to identify, mitigate, and escalate patient risk by using principles of high-reliability organizations. We hypothesized that our novel care system would decrease transfers determined to be unrecognized situation awareness failures events (UNSAFE). These were defined as any transfer from an acute care floor to an ICU where the patient received intubation, inotropes, or ≥3 fluid boluses in first hour after arrival or before transfer.

METHODS: The setting for our observational time series study was a quaternary care children’s hospital. Before initiating tests of change, 2 investigators reviewed recent serious safety events (SSEs) and floor-to-ICU transfers. Collectively, 5 risk factors were associated with each event: family concerns, high-risk therapies, presence of an elevated early warning score, watcher/clinician gut feeling, and communication concerns. Using the model for improvement, an intervention was developed and tested to reliably and proactively identify patient risk and mitigate that risk through unit-based huddles. A 3-times daily inpatient huddle was added to ensure risks were escalated and addressed. Later, a “robust” and explicit plan for at-risk patients was developed and spread.

RESULTS: The rate of UNSAFE transfers per 10 000 non-ICU inpatient days was significantly reduced from 4.4 to 2.4 over the study period. The days between inpatient SSEs also increased significantly.

CONCLUSIONS: A reliable system to identify, mitigate, and escalate risk was associated with a near 50% reduction in UNSAFE transfers and SSEs.

KEY WORDS
  • patient safety
  • situation awareness
  • rapid response systems
  • clinical deterioration
  • quality improvement
  • high-reliability organizations
  • hospital medicine
  • Abbreviations:
    ACA —
    apparent cause analysis
    EHR —
    electronic health record
    HRO —
    high-reliability organization
    MPS —
    manager of patient services
    MRT —
    medical response team
    PEWS —
    pediatric early warning score
    RRT —
    rapid response team
    SA —
    situation awareness
    SOD —
    safety officer of the day
    SSE —
    serious safety event
    UNSAFE —
    unrecognized situation awareness failure event
    • Accepted July 26, 2012.
    • Copyright © 2013 by the American Academy of Pediatrics

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    1 Jan 2013
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    Improving Situation Awareness to Reduce Unrecognized Clinical Deterioration and Serious Safety Events
    Patrick W. Brady, Stephen Muething, Uma Kotagal, Marshall Ashby, Regan Gallagher, Dawn Hall, Marty Goodfriend, Christine White, Tracey M. Bracke, Victoria DeCastro, Maria Geiser, Jodi Simon, Karen M. Tucker, Jason Olivea, Patrick H. Conway, Derek S. Wheeler
    Pediatrics Jan 2013, 131 (1) e298-e308; DOI: 10.1542/peds.2012-1364

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    Improving Situation Awareness to Reduce Unrecognized Clinical Deterioration and Serious Safety Events
    Patrick W. Brady, Stephen Muething, Uma Kotagal, Marshall Ashby, Regan Gallagher, Dawn Hall, Marty Goodfriend, Christine White, Tracey M. Bracke, Victoria DeCastro, Maria Geiser, Jodi Simon, Karen M. Tucker, Jason Olivea, Patrick H. Conway, Derek S. Wheeler
    Pediatrics Jan 2013, 131 (1) e298-e308; DOI: 10.1542/peds.2012-1364
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