Reducing Ischemic Injury From Indwelling Peripheral Arterial Catheters in a Pediatric Cardiac ICU: A Quality Improvement Initiative.

Objectives: To reduce the number of ischemic arterial catheter injuries in children with congenital or acquired heart disease.

Design: This is a quality improvement study with pre- and postintervention groups.

Setting: University-affiliated pediatric cardiac center in a quaternary care freestanding children's hospital.

Development and Preliminary Testing of the Coordination Process Error Reporting Tool (CPERT), a Prospective Clinical Surveillance Mechanism for Teamwork Errors in the Pediatric Cardiac ICU.

Background: Patient safety reporting systems (PSRSs) may not detect teamwork or coordination process errors that affect all dimensions of quality defined by the Institute of Medicine. This study aimed to develop and observe the performance of a novel tool, the Coordination Process Error Reporting Tool (CPERT), as a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Methods: Providers and parents used the qualitative nominal group technique to identify coordination process error examples.

Improving Cardiac Surgical Site Infection Reporting and Prevention By Using Registry Data for Case Ascertainment.

Background: The use of administrative data for surgical site infection (SSI) surveillance leads to inaccurate reporting of SSI rates [1]. A quality improvement (QI) initiative was conducted linking clinical registry and administrative databases to improve reporting and reduce the incidence of SSI [2].

Methods: At our institution, The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and infection surveillance database (ISD) were linked to the enterprise data warehouse containing electronic health record (EHR) billing data.

Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety.

High-risk low-volume therapies are those therapies that are practiced infrequently and yet carry an increased risk to patients because of their complexity. Staff nurses are required to competently manage these therapies to treat patients' unique needs and optimize outcomes; however, maintaining competence is challenging. This article describes implementation of Just-in-Time Training, which requires validation of minimum competency of bedside nurses managing high-risk low-volume therapies through direct observation of a return-demonstration competency checklist.