Background: We observed that clinical pages in our institution on both medical and surgical services do not always reach the primary inpatient provider. Because we use pagers to communicate critical, time-sensitive information, delayed or misdirected communication can adversely impact patient care. Purpose: Our goal was to quantify the frequency with which pages did not reach [...]

Background:  While many institutions train housestaff to mitigate hospital hazards, few have exploited the crucial concept of situational awareness (i.e. mindfulness of the patient environment) to teach patient safety. One method to promote situational awareness is through the embedding of safety and low-value care hazards into simulation-based training exercises. Purpose: To assess incoming interns’ ability [...]

Background: Failure to follow-up results of laboratory tests pending at discharge (TPADs) can lead to patient harm. Numerous interventions have been proposed to improve follow-up. The Laboratory Medicine Best Practices (LMBP™) workgroup, sponsored by the Centers for Disease Control, commissioned a systematic review to address the impact of various interventions on TPAD documentation, communication, and [...]

Background: Medication education for patients and caregivers can significantly impact patient safety. New medications are often introduced during a patient’s acute hospitalization. Without proper education, patients may not recognize these medications, their indications or their potential side effects. Printable electronic information may be insufficient as each medication may be associated with an overwhelmingly exhaustive list [...]

Background: Clinicians rely on physiologic monitor alarms to notify them of their patients’ changing vital signs. Currently, alarms occur very frequently and usually do not warrant clinical intervention. High alarm burden can lead to alarm fatigue, often observed as a slower response or unintentional ignoring of clinically important alarms. For this reason, alarm fatigue has [...]

Background: Resuscitation is a vital part of pediatric residents’ education; however, evidence has shown that during a 3 year residency period, live code blue scenarios in pediatrics are rare due to the low number of cardiopulmonary arrests in the pediatric population. Therefore, many residents do not feel confident in leading a code blue upon completion [...]

Background: Despite the growing emphasis on high-quality HCT, there remains a paucity of evidence to guide inpatient providers in transitioning adolescents to adult medical care. An inter-professional team at our institution created a video incorporating Self-Determination Theory (SDT) concepts as the educational construct emphasizing key elements of HCT.   The objectives were to determine the effect [...]

Background: Improved outcomes in pediatric to adult-oriented HCT especially for children with special health care needs (SHCN) are a national objective of Healthy People 2020, with only 40% of adolescents with SHCN currently meeting the national core outcomes in pediatric to adult-oriented HCT. Despite the potential of hospitalized AYA being higher utilizers of the health [...]

Background: We previously reported an estimate of the national pediatric (ped) bed census that demonstrated a 4% loss of total med/surg/PICU beds from 2002 to 2011. A deeper look revealed -7% med/surg beds, +12% PICU beds, a loss in beds at small (sm) and medium (med) sized hospitals as well as non-freestanding children’s (nonCH) hospitals [...]

Background: The transition from hospital to home presents a safety risk to pediatric patients. Literature suggests the needs and outcomes of technology-supported patients (TSP) differ from other patients. Objective: To determine differences between TSP and non-TSP for Project IMPACT process measure implementation: teach-back education; discharge readiness checklist; inpatient to outpatient handoff; post discharge phone call [...]