Epidemiology of diagnostic errors in pediatric emergency departments using electronic triggers.

Objectives: We applied three electronic triggers to study frequency and contributory factors of missed opportunities for improving diagnosis (MOIDs) in pediatric emergency departments (EDs): return visits within 10 days resulting in admission (Trigger 1), care escalation within 24 h of ED presentation (Trigger 2), and death within 24 h of ED visit (Trigger 3).

Methods: We created an electronic query and reporting template for the triggers and applied them to electronic health record systems of five pediatric EDs for visits from 2019. Clinician reviewers manually screened identified charts and initially categorized them as "unlikely for MOIDs" or "unable to rule out MOIDs" without a detailed chart review.

Improving oral health screening and dental referrals for patients with diabetes in a community health clinic.

Background: Oral health screening and access to dental care in adults with diabetes lead to improved health outcomes and quality of life. Patients with barriers to accessing health services have a greater risk of poor medical and dental outcomes. People with diabetes are more likely to have periodontal disease and less likely to visit a dentist.

Reducing Erythrocyte Sedimentation Rate Ordering: De-implementation and Diagnostic Stewardship.

Objectives: The Choosing Wisely campaign recommends against the routine use of erythrocyte sedimentation rate (ESR) for the assessment of acute undiagnosed inflammation or infection. We examined ESR and C-reactive protein (CRP) ordering practices at a large, freestanding children's hospital. We found that 80% of ESR orders were placed concurrently with a CRP order.

Professional identity in nursing: Why it is important in graduate education.

Possessing a clear identity in nursing is a guiding principle to professional comportment. In graduate nursing education, transitioning and expanding one's professional identity requires role evolution. Nurses transitioning into the advanced professional nursing role shifts their thinking to a new level.

A quality improvement project to improve treatment of severe hypertriglyceridemia in veterans.

Background: Severe hypertriglyceridemia (sHTG) is associated with an increased risk of acute pancreatitis. Prompt recognition and treatment of sHTG is key for prevention of acute pancreatitis and its associated life-threatening complications.

Local Problem: Patients with sHTG at a primary care clinic within the Veterans Affairs Eastern Colorado Health Care System were receiving suboptimal treatment that did not align with evidence-based guidelines.

Research Priorities for Pediatric Emergency Care to Address Disparities by Race, Ethnicity, and Language.

Importance: Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking.

Objective: To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations.

A quality improvement initiative to improve folic acid supplementation counseling for adolescent females with epilepsy.

Objective: We designed a quality improvement (QI) project to improve rates of documented folic acid supplementation counseling for adolescent females with epilepsy, consistent with a quality measure from the American Academy of Neurology and American Epilepsy Society. Our SMART aim was to increase the percentage of visits at which folic acid counseling was addressed from our baseline rate of 23% to 50% by July 1, 2020.

Methods: This initiative was conducted in female patients ≥12 years old with epilepsy who were prescribed daily antiseizure medication and were seen by the 13 providers in our Neurology QI Program.

Opportunities for Diagnostic Improvement Among Pediatric Hospital Readmissions.

Objectives: Diagnostic errors, termed "missed opportunities for improving diagnosis" (MOIDs), are known sources of harm in children but have not been well characterized in pediatric hospital medicine. Our objectives were to systematically identify and describe MOIDs among general pediatric patients who experienced hospital readmission, outline improvement opportunities, and explore factors associated with increased risk of MOID.

Patients And Methods: Our retrospective cohort study included unplanned readmissions within 15 days of discharge from a freestanding children's hospital (October 2018-September 2020).

Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit.

Background: Late recognition of in-hospital deterioration is a source of preventable harm. Emergency transfers (ET), when hospitalized patients require intensive care unit (ICU) interventions within 1 h of ICU transfer, are a proximal measure of late recognition associated with increased mortality and length of stay (LOS).

Objective: To apply diagnostic process improvement frameworks to identify missed opportunities for improvement in diagnosis (MOID) in ETs and evaluate their association with outcomes.

Resident Communication With Patients and Families Preferring Languages Other Than English.

Objectives: Patients and families preferring languages other than English (LOE) often experience inequitable communication with their health care providers, including the underutilization of professional interpretation. This study had 2 aims: to characterize resident-perceived communication with families preferring LOE and to evaluate the impact of language preference on frequency of resident interactions with hospitalized patients and families.

Methods: This was a cross-sectional study at a quaternary care children's hospital.

Innovative DNP Evaluation Tools.

Innovative strategies are crucial for addressing essential faculty knowledge for teaching and advising Doctor of Nursing Practice (DNP) students, especially during the phase of time-sensitive scholarly projects. Challenges of diverse educational and experiential background of faculty may contribute to inconsistent student advisement and learning. Lack of clear expectations creates barriers to student learning.

Clinical pathways and diagnostic reasoning: A qualitative study of pediatric residents' and hospitalists' perceptions.

Background: Clinical pathways are evidence-based guidelines adapted to local settings. They have been shown to improve patient outcomes and reduce resource utilization. However, it is unknown how physicians integrate clinical pathways into their clinical reasoning.

Applying a diagnostic excellence framework to assess opportunities to improve recognition of child physical abuse.

Objectives: Diagnostic excellence is an important domain of healthcare quality. Delays in diagnosis have been described in 20-30% of children with abusive injuries. Despite the well characterized epidemiology, improvement strategies remain elusive.

Implementation of a Multidisciplinary Debriefing Process for Pediatric Ward Deterioration Events.

Objectives: Event debriefing has established benefit, but its adoption is poorly characterized among pediatric ward providers. To improve patient safety, our hospital restructured its debriefing process for ward deterioration events culminating in ICU transfer. The aim of this study was to describe this process' implementation.

Identifying trigger concepts to screen emergency department visits for diagnostic errors.

Objectives: The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.

Procedural Training in Pediatric Emergency Medicine Fellowship: What Are We Teaching and What Do Fellows Need to Learn?

Background: Life-saving procedures are rarely performed on children in the emergency department, making it difficult for trainees to acquire the skills necessary to provide proficient resuscitative care for children. Studies have demonstrated that residents in general pediatrics and emergency medicine lack exposure to procedures in the pediatric context, but no studies exist regarding procedural training in pediatric emergency medicine (PEM). Although the Accreditation Council for Graduate Medical Education (ACGME) provides a list of procedures in which PEM fellows must be competent, the relevance of this procedure list to actual PEM practice has not been studied.

Improving Disposition Decision-Making for Pediatric Diabetic Ketoacidosis: A Quality Improvement Study.

Introduction: In many centers, children with diabetic ketoacidosis (DKA) receive care either in an endocrinology ward or a pediatric intensive care unit (PICU). We conducted a quality improvement (QI) initiative to reduce potentially avoidable PICU admissions of children with DKA without increasing endocrinology ward-to-PICU transfers.

Methods: A survey of providers demonstrated opportunities to increase awareness of institutional criteria for PICU admissions of children with DKA.

A Framework for Quality Assurance of Pediatric Revisits to the Emergency Department.

Background: Emergency department return visits significantly impact medical costs and patient flow. A comprehensive approach to understanding these patients is required to identify deficits in care, system level inefficiencies, and improve diagnosis specific management protocols. We aimed to identify factors needed to successfully analyze return visits to explore root causes leading to unplanned returns and inform system-level improvements.

Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient safety.

Background: Academic fellowships in quality improvement (QI) and patient safety (PS) have emerged as one strategy to fill a need for physicians who possess this expertise. The authors aimed to characterise the impact of two such programmes on the graduates and their value to the institutions in which they are housed.

Methods: In 2018, a qualitative study of two US QIPS postgraduate fellowship programmes was conducted.