Publications by authors named "Elizabeth Kloppenborg"

Background: Historically, the gold standard for detecting medical errors has been the voluntary incident reporting system. Voluntary reporting rates significantly underestimate the number of actual adverse events in any given organization. The electronic health record (EHR) contains clinical and administrative data that may indicate the occurrence of an adverse event and can be used to detect adverse events that may otherwise remain unrecognized.

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Objectives: To evaluate and characterize the Global Trigger Tool's (GTT's) utility in a pediatric population; to measure the rate of harm at our institution and compare it with previously established trigger tools and benchmark rates; and to describe the distribution of harm of the detected events.

Methods: Per the GTT methodology, 240 random inpatient charts were retrospectively reviewed over a 12-month pilot period for the presence of 53 predefined safety triggers. When triggers were detected, the reviewers investigated the chart more thoroughly to decide whether an adverse event occurred.

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Article Synopsis
  • Hyperglycemia is common in critically ill children and is linked to poor outcomes, but insulin treatment can cause hypoglycemia in up to 25% of cases which may worsen mortality risks.
  • An insulin infusion guideline was developed for nondiabetic pediatric ICU patients, detailing infusion initiation, monitoring, and management of low blood sugar episodes.
  • After the guideline was put in place, hypoglycemic events dropped significantly from 36% to 3%, and the average time between such events increased drastically, showing the effectiveness of the new management protocol.
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  • Narcotics often cause adverse drug events in children, particularly opioid oversedation in hospitalized patients.
  • Objectives focused on improving methods to prevent opioid oversedation during perioperative care while ensuring effective pain management.
  • Results showed a significant decrease in opioid-related oversedation events and an increase in the interval between these incidents, highlighting the effectiveness of revised prescribing practices and enhanced sedation assessments.
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