• Conference/Meeting
  • March 17-22, 2019

2019 Quality and Safety in Children's Health Conference

  • Achieving High Reliability in Preventable Harm

    Johns Hopkins All Children’s Hospital designed a weekly preventable harm huddle to create structure and process to support the discussion of such events with hospital leadership and hospital-acquired condition leaders to facilitate action and accountability. The huddle promotes sharing of events that result in patient and/or staff harm, root causes of these events and lessons learned to assist with the prevention of similar events in the future.

  • "Beyond the Bundle" Using Data and Technology to Reduce CAUTI

    Despite maintaining 90 percent or greater maintenance compliance on reduce catheter-associated urinary tract infections (CAUTI), Children’s Hospital Colorado continued to see infections. Using data and technology, The hospital revamped improvement efforts to focus on catheter duration.

  • Development, Implementation and Sustainment of an Enterprise-Wide Disclosure Program

    Children’s Hospital & Medical Center created an Adverse Event Disclosure Program to support the organization in providing safe, high-quality care and to assist providers and employees with the disclosure of adverse events. Resources included a disclosure policy, disclosure support documents, and 48 specially trained disclosure coaches.

  • Febrile Neonates: Treating Small Patients with Big Risks

    The threshold for timely antibiotic treatment for febrile neonates is 60 minutes. Monroe Carell Jr. Children’s Hospital at Vanderbilt aimed to reduce the time from patient arrival in the pediatric emergency department to time of antibiotic administration for febrile neonates age 0-28 days. Within that time limit staff reduced average time to antibiotics through standardization and workflow changes.

  • Gastric Feeding on HFNC in Pediatric Critical Care Units

    Historically, children in Intensive Care Units on high flow nasal cannula (HFNC) received post pyloric feeds or remained NPO (nothing by mouth) until they were at or below four liters of flow. Staff at Duke Children’s Hospital & Health Center hypothesized that initiation of early gastric feeds on reasonable levels of HFNC support would be safe and well tolerated.

  • Initiation of Multi-Disciplinary, Family-Centered Rounds in Pediatric Hematology/Oncology

    To facilitate communication between the medical team and the patient and family, Phoenix Children’s Hospital started multidisciplinary bedside, family centered rounds on the in Pediatric Hematology/Oncology. The hospital used appointment-based rounds to improve workflow and inform parents when to expect the team. Patient satisfaction scores have improved since beginning family-centered rounds.

  • Low Volume High Risk Preventing Vitamin K Refusal

    Vitamin K provided in the neonatal period is a safe and effective at preventing what can catastrophic hemorrhagic disease of the newborn. Despite the benefit, parental refusal has increased since the 1990s. Joe DiMaggio Children’s Hospital at Memorial Regional Hospital created a simple alert that has decreased cases of parental refusal.

  • Managing Methadone Weaning Protocol and Withdrawal Assessment

    Joe DiMaggio Children’s Hospital at Memorial Regional Hospital created processes to address a lack of a protocol for weaning opiate-dependent patients and introduced a withdrawal assessment tool. The changes related to methadone exposure and opiate withdrawal in pediatric patients receiving five or more days of continuous morphine or fentanyl infusions.

  • Minimizing Occlusion Alarms Following Implementation of Filter Tubing for Lipids

    After adding filtered tubing for lipid infusions, reports of occlusion alarms with lipid products increased.. Staff at Children’s Hospitals and Clinics of Minnesota aimed to determine what factors contributed to the alarm rise and develop a solution. The hospital strived to reduce occlusion alarms to the baseline rate experienced prior to the introduction of the filtered tubing.

  • Move from the Bottom Percentile to Top 50 Ranking

    WVU Medicine Children’s used national ranking programs to effectively conduct a gap analysis, prioritize improvements, and affect the organization’s care and services.

  • Multidisciplinary Quality Improvement Education Across a Pediatric Primary Care Network

    Frontline clinical and administrative staff can encounter barriers to quality improvement (QI) work. Children’s Hospital of Philadelphia developed a multidisciplinary QI curriculum for staff in the hospital’s primary care network to help them engage in QI work to improve the care they provide patients and families each day.

  • Outpatient Bronchiolitis Clinic Reduces Readmissions and Resource Utilization

    Bronchiolitis is a common cause of hospitalization in pediatrics, associated with high health care costs. Joe DiMaggio Children’s Hospital at Memorial Regional Hospital started a bronchiolitis clinic with the goal of improving patient safety and quality of care in-hospital and after discharge. Results show decreased rates of readmission, emergency department visits, and increased family satisfaction.

  • Pediatric Sepsis Recognition in Community Emergency Rooms

    With the guidance of Advocate Children’s Hospital’s sepsis committee, the eight community hospital emergency rooms in the integrated health system will undergo tabletop exercises, piloting and required education modules to prepare for implementation of pediatric sepsis screening, recognition and use of care pathways.

  • Proceed Until Apprehended: A Cultural Transformation

    Leadership at Children’s Hospital supports the transition to a culture that has frontline team members finding and adopting solutions that will positively affect the quality of patient outcomes, staff engagement, and patient experience. The hospital refers to this approach as “Proceed Until Apprehended”, which further empowers team members.

  • Promote Fertility Preservation in Children Facing Chemotherapy

    Childhood cancer survival rates have improved drastically with over 85 percent becoming long-term survivors. As a result of chemotherapy, the survivors continue to suffer health consequences such as loss of reproductive potential. Mayo Clinic Children’s Center started a fertility preservation program for children in puberty or pre puteral via storage of sperm or eggs and testicular or ovarian tissue.

  • Quality Assessment of Instrument-Based Preschool Vision Screening

    Instrument-based vision screenings replaced chart-based vision screening for preschoolers during well child visits at St. Luke’s Children’s. The introduction of the different screening system improved exam efficiency, was highly adopted by providers and well accepted by caregivers.

  • Reliable Hazard Reduction in MRI

    The risk of items becoming magnetic projectiles in MRI suites is well documented, but strategies to reduce these risks are not. Children’s Hospital Colorado used an interdisciplinary process improvement method to reduce both the frequency of alarms, and the frequency of iron metal objects entering an MRI scanner, also known as Zone 4 space.

  • Resident-Driven Safety Initiatives

    The Pediatric Residency Safety Council (PRSC) is a resident-led organization at Duke Children’s Hospital & Health Center that seeks to improve patient safety through review of safety reports and creation of action items. Recent improvements in resident education and patient safety include out-of-ICU code reviews and flow-diagrams to assist with decision making.

  • Sepsis e-Learning Curriculum: Leveraging “Confidently Held Misinformation” and “Learner Struggle”

    Children’s Hospital Colorado developed sepsis eLearning courses for emergency department and non-ICU inpatient personnel. Staff created the content by reviewing institutional practice and national guidelines. An online dashboard displayed results—including Confidently Held Misinformation and Struggle—to identify risk areas and knowledge gaps. Non-progress attempts—where response accuracy and confidence did not improve with repetition—identified individual opportunities for intervention.

  • Sustaining a Culture of Safety through Recognition and Celebration

    Yale New Haven Children’s Hospital developed an initiative to empower front-line staff through safety education, recognition and celebration. The organization expanded its strategy to report new miss events. This was seen as a key strategy to build and sustain a culture of safety with a focus on frontline staff and providers.