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quality metrics. An extension of the P4P concept relates to the implemen- tation of the policy of nonreimbursable hospital-acquired con- ditions, formerly called never events by the Centers for Medicare and Medicaid Services (CMS). CMS has identified a list of hospital- acquired conditions, which are specific quality... |
in practice patterns among Implementation of Six Sigma Process (e.g., Error rates) Significant variation Reduction in variation Mean performance Overall improvement with less variation Fig 4.7 Run or SPC chart with common cause and special cause vari- ation. Individual QI Project Districts and Chapters National Impleme... |
be used by states and in a variety of other settings to evaluate quality of care for children. Third, reform advocated a paradigm shift in the existing model of healthcare delivery from vertical inte- gration toward a model of horizontal integration. This has led to the creation and rapid growth of integrated delivery ... |
the National Association of Children’s Hospitals and Related Institutions and the Child Health Corporation of America Databases, QI collaboratives, and policy Institute for Healthcare Improvement (IHI) QI organization for adult and pediatric care QI collaboratives, QI educational workshops and materials National Initi... |
ientsafety.org) and uses a learning network model to pursue the aim of eliminating serious harm across all children’s hospi- tals. In addition, healthcare has recognized the high rates of healthcare worker injury and the critical role that the safety of healthcare provid- ers plays in outcomes, burnout, and safe patien... |
NCC-MERP) Index for medication- related harm and the severity scales for all-cause harm. Serious safety events (SSEs) are deviations from expected practice followed by death or severe harm. The SPS collaborative has SSE elimina- tion as its primary goal. Sentinel events or never events, such as a wrong-site surgery... |
of system resilience, particularly in the midst of high levels of risk and stress, as often seen in healthcare. Chapter 5 Safety in Healthcare for Children Patrick W. Brady, Tina K. Sosa, and Jeffrey M. Simmons Error Harm No harm Preventable harm Non-preventable harm Fig. 5.1 Overlap between error and harm. Downloaded ... |
for age. What other thoughts does the team have?”). It is often easier and more feasible to give feedback in a simulated scenario versus a real event. Low-fidelity simulation does not require costly simulated patients and may have advantages in identifying latent threats in the hospital or clinic. For example, a simul... |
, and goals. Apparent cause analysis, common cause analysis, and failure modes and effects analysis are complementary learning methods. Apparent cause analysis is performed by a smaller multidisci- plinary team to look primarily for proximal causes, making it fea- sible for events that occur often (e.g., the wrong medi... |
as opportu- nities to improve the system, rather than as the personal failures of individual clinicians. Just culture differentiates the mistakes and wrong decisions that a clinician makes commensurate with their training and experience from willful violations and gross or repeated patterns of negligence. A safety cult... |
must be intentionally designed with tools and concepts based on the principles of human factors engineering and reliability science. These processes include creating intentional redundancy, such as independent verification on high-risk medication dosing, and making the default action the desired action based on eviden... |
measure in a hypothetical CLA-BSI project. In this case, after improvement interventions targeted two process measures known to be impor- tant in CLA-BSI risk—the line insertion and the line maintenance bundles—the QI team saw improvement in both measures and coincident reduction in CLA-BSIs. A safety culture and ex... |
PEWS take these diverse exam elements and combine them into a single score, which when coupled with clear, expected actions (e.g., evaluation by physician at score of 5, evaluation by rapid response team at score of 7) may better detect deterioration and improve safety outcomes. PEWS are one method of improving a clini... |
events in the pediatric ICU. Cardiopulmonary arrest rates outside of the ICU are useful metrics to evaluate the performance of rapid response systems in adult patients. Given that these events are quite rare in pediatrics, and increasingly so since the implementation of rapid response systems, the identification of val... |
, co-ordering of laxatives in patients on opiates Peripheral IV infiltrates Moderate or serious harm (e.g., diminished pulses, >30% swelling) associated with a peripheral IV infiltrate (details at http://www.solutionsforpatientsafety.org) — Hourly reviews of IV status, limitations on use of desiccants through peripher... |
). Safety culture is critical to both the open acknowledgment of diagnostic uncertainty and the willingness to discuss and learn from diagnostic error when it occurs. The 2015 National Academy of Medicine (NAM) report entitled Improving Diagnosis in Health Care emphasized the centrality of 01/01/17 01/08/17 01/15/17 01... |
University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Chapter 5 u Safety in Healthcare for Children 47 communication to patients and families in the diagnostic pro- cess while int... |
operatively) More common than code events and other proximal metrics to arrest High sensitivity for unrecognized deterioration Low specificity for unrecognized deterioration Often requires time-intensive manual review of ICU transfers Site-specific parameters, including definition adjustments, and the acuity of patie... |
arrest Low sensitivity for inadequately recognized, subacute cases of deterioration Not inclusive of all nonrespiratory etiologies of deterioration Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other... |
characteristics or motivations of others, whether they are the patient, the patient’s family, or other members of the evaluation team. Countertransference Being influenced by positive or negative subjective feelings toward a specific patient. Outcome bias Minimizing or overemphasizing the significance of a finding or r... |
, Kliegman R. Overcoming diagnostic errors in medical practice. J Pediatr. 2017;185:19–25, Table III. Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Els... |
children receiving chemotherapy used direct observation by a trained nurse at home and found approximately 70 errors per 100 patients, many of which were serious or significant. Families often make dosing errors Table 5.6 Diagnostic Time-Out • Identify the clinical issues, dilemmas, or concerns needing a time-out. ... |
accumulated diagnostic labels, regardless of who applied the label. 6. Improving hypothesis testing • Know the limitations of laboratory tests (i.e., false positives and negatives). • Do not be so quick to “rule out” a diagnosis: consider the posttest likelihood of a disease in terms of a probabilistic analysis tha... |
use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 50 Part I u The Field of Pediatrics in administering liquid medications, particularly when using kitchen spoons rather than dosing syringes. A health literacy–informed pic- togram reduces the rates of these errors Additional... |
. A systematic review of the evidence in pediatric appendi- citis found that social, racial, and economic inequities exist in the rate of misdiagnosis, laparoscopic versus open approach, length of stay, and appendiceal perforation rate. In pediatric severe sepsis, a recent large retrospective study found evidence of an... |
Fig. 5.4 Outcomes from the diagnostic process. (From National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care https://doi.org/10.17226/21794.) Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20,... |
surrogate or proxy decision made by a parent on behalf of a child. It is constrained by the child’s best interest, even if this places the clinician in conflict with the parent. In any given instance, the decision of what is or is not in a child’s best interest may be difficult, especially given the diverse views of ac... |
legally. The adolescent’s parent(s) remain in a guiding and protective role. The process of communica- tion and negotiation will be more complex should disagreement arise between the parent and adolescent. Pediatricians can be effective inter- cessors when these situations arise, making use of communication skills in a... |
physiologic outcome, forgoing a particular intervention is ethically justified. However, this approach may not adequately engage professionals and families in understanding facts and values that might allow the same therapy to reach other goals and may leave medical and family stakeholders in permanent conflict. Guidan... |
detract from quality of life regardless of the impact on a child’s underlying dis- ease process, and as such are important whether care is focused on cure or on transitioning to end-of-life care (see Chapter 8). Some interventions regarded as life-sustaining, such as chemotherapy, may be ethically accept- able in th... |
’s clinical condition, balancing benefits and burdens to the patient. Resus- citation should not be performed solely to mollify parental distress at the tragic time of the loss of their child. Artificial Hydration and Nutrition Issues surrounding withholding or withdrawing artificial hydration and nutrition are controv... |
that competent patients ≥18 yr have a constitutionally protected right to refuse unwanted medical treatments. NO. In neonates and children, if the treatment is in the best interest of the child, the family cannot refuse beneficial treatments (see later). What interventions can be legally and ethically terminated? Any a... |
able occurrence of unavoidable side effects. Hastening death as a primary intention is not considered to be morally acceptable. Providing pain medication guided by the DDE should not be con- fused with active euthanasia. The distinction is clear: • In active euthanasia, causing death is chosen as a means of relieving ... |
ative care approaches in infants have become more available and skilled, balanced approaches to valuing the lives of disabled infants should be considered. Understanding institutional, regional, state, and national regulations related to care of infants is important in order to practice within regulatory frame- works w... |
JECTIONS TO TREATMENT Differences in religious beliefs or cultural norms may lead to conflict among patients, families, and medical caregivers over the approach to medical care. Pediatricians need to remain sensitive to and maintain an attitude of respect for these differences yet recognize that an independent obligati... |
a- tures. Another framework based on principles would suggest attention to respect for persons, beneficence/nonmaleficence, and justice. Pediatric ethics committees often play a constructive role when parents and medical staff cannot agree on the proper course of action. Over the past several decades, these committees ... |
permission or refusal. However, once a particular screening test has been clearly demonstrated to benefit the individual or public health, a formal, active parental permission pro- cess may not be ethically obligatory. A persistent ethical issue is whether screening should be (1) vol- untary (“opt in”), (2) routine, wi... |
initiated in childhood. Otherwise, such testing should be deferred until the child has the capacity to make an informed and voluntary choice. Precision medicine promises to enhance treatment and public health outcomes in the future. Yet the success of precision medicine will depend on whose data are used to develop and... |
and adolescent care. As adolescents mature, their need to exchange information about sensitive topics can increase, complicat- ing the triadic clinician-parent-child relationship. For example, ado- lescents might wish to start oral contraception or seek treatment for a sexually transmitted infection without their par... |
, because of illness, they have not been able to achieve normal developmental milestones or psychologic maturity. The clinician’s role involves assessment of the individual adolescent patient’s ability to understand the medical situation, to support the patient’s efforts to express wishes regarding medical treatment, t... |
in contrast to the risk level acceptable for research with consenting adults. These restrictions function by limiting the type of research that institutional review boards (IRBs) are permitted to approve and by specifying the conditions under which parents have the moral and legal authority to permit a child to par- ti... |
apeutic research, when there cannot be a claim that participation is in the child’s interest. In the United States, national regulations require that reasonable efforts be made at least to inform children who are capable of understanding that participation is not part of their care, and therefore they are free to refus... |
justice system, and lower executive function- ing. Pediatricians should take active steps to acknowledge and attempt to mitigate the effect of these inequalities on their patients through individual, local, and national advocacy efforts. Visit Elsevier eBooks+ at eBooks.Health.Elsevier.com for Bibliography. Downloaded ... |
with traditional medical management for these common pediatric conditions. DIETARY SUPPLEMENTS Under the 1994 U.S. Dietary Supplement Health and Education Act, a dietary supplement is a product taken by mouth that contains a dietary ingredient intended to supplement the diet. These may include vitamins, minerals, herbs... |
new- borns, patients with impaired renal or hepatic function), under special circumstances (e.g., after organ transplantation or other surgery), or when combined with prescription medications. Some natural products are toxic in and of themselves. Even when a product is safe when used correctly, it can cause mild or sev... |
in the United States, dietary supplement labels might not accurately reflect the contents or concentrations of ingredients. Because of natural variability, variations of 10-fold to 1,000-fold have been reported for sev- eral popular herbs, even across lots produced by the same manufacturer. Herbal products may be con... |
beneficial for pediatric patients with asthma, insomnia, colic, cystic fibrosis, or juvenile arthritis and patients undergo- ing cancer therapy. Massage therapy is generally safe. Professional mas- sage practice is regulated by state government and may be in the form of a license, registration, or certification. More t... |
In the United States, acu- puncturists are licensed to practice in 47 states. Acupuncture can be delivered to pediatric patients in hospital and clinic settings to treat a variety of ailments. Acupuncture is particularly useful for children experiencing pain, and acupuncture services are offered alongside conventional ... |
are often amenable to acupuncture and report that it is helpful. Acupuncture can offer significant benefits in the treatment of recurrent headache, anxiety, back and other types of pain, depression, abdominal pain, and nausea. Infections and bleeding are rare but can occur, and more serious complications, such as pneu-... |
Tai chi Improving balance, coordination, concentration, and discipline Yoga Improving balance, coordination, and concentration ADHD, Attention-deficit/hyperactivity disorder. According to the World Health Organization (WHO), “Palliative care for children is the active total care of the child’s body, mind and spirit an... |
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