Safety Rounds in Ambulatory and
Inpatient Settings
Wednesday, October 25, 2006
12:00 – 1:00 p.m. EDT
Moderator:
Uma Kotagal, MD, MBBS, MSCE, FAAP
Vice President for Quality and Transformation
Director, Center for Health Policy & Clinical Effectiveness
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
This activity was funded through an
educational grant from the Physicians’
Foundation for Health Systems
Excellence.
Disclosure of Financial Relationships and
Resolution of Conflicts of Interest for AAP CME Activities Grid
The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional
performance of pediatric healthcare professionals by providing high quality, relevant, accessible and
cost-effective educational experiences. The AAP CME program provides activities to meet the
participants’ identified education needs and to support their lifelong learning towards a goal of
improving care for children and families (AAP CME Program Mission Statement, August 2004).
The AAP recognizes that there are a variety of financial relationships between individuals and commercial
interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on
Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is
designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by
identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in
a position to influence and/or control CME content. The AAP has taken steps to resolve any potential
conflicts of interest.
All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical
Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME
Activities. In accordance with these Standards, the following decisions will be made free of the control
of a commercial interest: identification of CME needs, determination of educational objectives, selection
and presentation of content, selection of all persons and organizations that will be in a position to
control the content, selection of educational methods, and evaluation of the CME activity.
The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to
resolve them prior to the CME activity are implemented in ways that are consistent with the public good.
The AAP is committed to providing learners with commercially unbiased CME activities.
DISCLOSURES
Activity Title:
Activity Date:
Safer Health Care for Kids - Webinar
Safety Rounds in Ambulatory and Inpatient Settings
October 25, 2006
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity
producing health
care goods
or services)
Nature of Relevant
Financial
Relationship(s)
(If yes, please list:
Research Grant,
Speaker’s Bureau,
Stock/Bonds excluding
mutual funds,
Consultant, Other identify)
CME Content Will
Include Discussion/
Reference to
Commercial
Products/Services
Disclosure of Off-Label (Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to disclose to the AAP and to
learners when they plan to discuss or demonstrate
pharmaceuticals and/or medical devices that are not approved
Kathy N. Shaw, MD,
MSCE, FAAP
No
No
No
No
Sara J. Singer, MBA
No
No
No
No
DISCLOSURES
SAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMM ITTEE AND STAFF
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant
Financial Relationship(s)
(If yes, please list:
Research Grant, Speaker’s
Bureau, Stock/Bonds
excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include
Discussion/
Reference to Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Karen Frush, MD, FAAP
(PAC Member)
No
No
No
No
Uma Kotagal, MD, MBBS,
MSc, FAAP (PAC Member)
No
No
No
No
Christopher Landrigan, MD,
MPH, FAAP (PAC Member)
No
No
No
No
Marlene R. Miller, MD, MSc,
FAAP (PAC Chair)
No
No
No
No
Paul Sharek, MD, MPH.
FAAP (PAC Member)
No
No
No
No
Erin Stucky, MD, FAAP (PAC
Member)
No
No
Not sure
No
Nancy Nelson (AAP Staff)
No
No
No
No
Melissa Singleton, MEd
(Project Manager – AAP
Consultant)
No
No
No
No
Junelle Speller (AAP Staff)
No
No
No
No
Linda Walsh, MAB (AAP
Staff)
No
No
No
No
DISCLOSURES
AAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME)
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant
Financial Relationship(s)
(If yes, please list:
Research Grant, Speaker’s
Bureau, Stock/Bonds
excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include
Discussion/
Reference to Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Ellen Buerk, MD, FAAP
No
No
No
No
Meg Fisher, MD, FAAP
No
No
No
No
Robert A. Wiebe, MD, FAAP
No
No
Not sure
No
Jack Dolcourt, MD, FAAP
No
No
No
No
Thomas W. Pendergrass, MD,
FAAP
No
No
No
No
Beverly P. Wood, MD, FAAP
No
No
No
No
CME CREDIT
The American Academy of Pediatrics (AAP) is accredited by
the Accreditation Council for Continuing Medical Education
to provide continuing medical education for physicians.
The AAP designates this educational activity for a maximum of
1.0 AMA PRA Category 1 Credit™. Physicians should only
claim credit commensurate with the extent of their
participation in the activity.
This activity is acceptable for up to 1.0 AAP credit. This credit
can be applied toward the AAP CME/CPD Award available to
Fellows and Candidate Fellows of the American Academy of
Pediatrics.
OTHER CREDIT
This webinar is approved by the National Association of
Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP
contact hours of which 0.0 contain pharmacology (Rx)
content. The AAP is designated as Agency #17. Upon
completion of the program, each participant desiring
NAPNAP contact hours should send a completed certificate
of attendance, along with the required recording fee ($10
for NAPNAP members, $15 for nonmembers), to the
NAPNAP National Office at 20 Brace Road, Suite 200, Cherry
Hill, NJ 08034-2633.
The American Academy of Physician Assistants accepts AMA
PRA Category 1 Credit(s)TM from organizations accredited by
the ACCME .
Featured Speaker:
Kathy N. Shaw, MD, MSCE, FAAP
Chief, Division of Emergency Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
OBJECTIVES
Upon completion of this activity, participants
will be able to:



Describe the process and explain the rationale for
senior leader-driven Safety Rounds in ambulatory
and inpatient settings.
List the types of safety issues identified on Safety
Rounds, and distinguish similarities and
differences between safety issues in ambulatory
and inpatient settings.
Select and apply at least one strategy to ensure
issues identified on Safety Rounds are efficiently
and effectively discussed with all appropriate
individuals and improvements are implemented.
The Children’s Hospital of Philadelphia
Emergency Department
Unit-Based Patient Safety WalkRounds
Kathy N. Shaw, M.D., M.S.C.E.
Chief, Division of Emergency Medicine
Professor of Pediatrics at CHOP
University of Pennsylvania School of Medicine
The Nicholas Crognale Endowed Chair
in Pediatric Emergency Medicine
Purpose of WalkRounds
• Mechanism for communicating with staff
about safety issues
• Signal staff on the front lines that there is
commitment to a culture of safety
• Foster open communication and
a blame-free environment
• Gather ideas to take action to make
a safer work place
Unit-based PSWR
• Stakeholders vs. visitors
• Ubiquitous vs. sporadic
• Rapid response and dissemination
of information vs. not . . .
When: Unit-based PSWR
• Minimum of 2 times / month
• All days of the week
• All times of the day
Participants: Unit-based PSWR
• Team leaders:
– PEM attending / 2 RNs
• Staff Participants:
– Resident
– ED nurse
– Clerical staff
– Social worker or Child Life therapist
– Respiratory therapist or Radiology tech
– Environmental Services or ED tech
Where: Unit-based PSWR
• CQI in patient care area of the ED (15-20 min)
• Group meeting in the ED conference room
(15-20 min)
Tool Kit: Unit-based PSWR
• Step by Step Guide to Conducting PSWR
• Quality Improvement Indicator Tools
• General Questions for Group Discussion
ED Based CQI Activities
• 4 team members complete CQI tools in ED
– Clinical observations
– Interviews with staff / parents
– Review of chart, electronic tracking and
ordering system
Quality Improvement Tools
1. Accuracy of weight and allergy documentation
RN or tech joins PSWR
2. Appropriateness of patient monitoring
and alarm parameters / central monitoring
RN joins PSWR
3. Reasons for prolonged ED length of stay > 3 hrs
Resident joins PSWR
Quality Improvement Tools
4.
Accuracy of medication orders, administration,
and documentation
ED RN or MD joins PSWR
5. Compliance with hand washing
RN joins PSWR; person from Environmental Services
identified to complete room check part of QI
6. Patient / family communication (directed at patient/caregiver)
Clerk or Social Work / Child Life or RN join PSWR
Conference Room Discussion
• Review purpose of PSWRs
• Open-ended general questions and discussion
with 5 individuals chosen from clinical area
• Discussion / information is reported without
identifiers to an individual
General Questions for PSWR Participants
• In your last few shifts, have you experienced any
“near misses” that almost caused patient harm but
were avoided? Have you noticed any incidents that
actually did result in patient harm? (please describe)
• What should be done to encourage reporting of
“near misses events?”
General Questions for PSWR Participants
• Based on discussion of near misses, please provide
suggestions on how we could improve the safety of
patients in our ED.
• Have you developed any personal practices to help
you prevent making errors in the ED?
• If you could fix one thing in the ED to make it a safer
place for patients, what would it be?
PSWR Follow-up
• Multidisciplinary team meets twice per month
- Reviews latest PSWR data and IR’s
- Follow-up report generated regarding issues
observed, resolution, and who is accountable
• Dissemination of ideas / results to staff
Our Experience
(First 9 Months)
• 20 Unit-based PSWR
• 30% on weekends,
65% on evenings / overnights
• 99 staff members participated
Lessons Learned
20% aborted and rescheduled
Orientation and Communication are Essential
• General
– each group of constituents
• Individual – leaders prior to PSWR
Discoveries and Actions
• Numerous issues identified
• Action items involved:
- Multiple services
- Education of staff
- New policies and procedures
- Occasional “quick fixes”
Patient / Family Communication Tool
Systems Issue:
Families could not identify staff roles
Solutions (unit-based):
Dry erase board in each room
with providers’ names
Bedside report and rounding
Hand-Washing Tool
Systems Issue:
Lack of alcohol hand-rub in each room
Solutions (multiple services):
Environmental Services
Environmental Health and Safety
Purchasing
Monitoring and Alarms
Systems Issue:
No standard for initiating CR mentoring
Lack of age-appropriate alarm parameter
Inaudible alarms
Solutions (unit-based and hospital-wide):
Standards established
Mandatory education on age-based parameters
Biomedical engineering to increase alarm volumes
Patient Safety Discussion
Systems Issue:
Staff unclear as to when or why to complete
incident reports; “tattling” vs. identification
and prevention
Solutions:
Staff communication (emails, meetings)
Emphasis on systems issues and solutions
Praising near-miss reporting
Feedback on PSWR / IR’s monthly
Medication “Near-Miss” Incident Reports
1
0.85
0.8
0.58
Rate per 1000
0.60
0.6
ED Patients
0.4
0.2
0
FY04
FY05
FY06
Conclusions: Unit-based PSWR
• Inspire staff to participate in making their
unit safe
• Identify multiple issues not reported
by usual practice
• Lead to multiple systems improvements
to improve patient safety
Further Information
Creating Unit-based Patient Safety Walkrounds in a
Pediatric Emergency Department
Kathy N. Shaw, MD, MSCE
Jane M. Lavelle, MD
Kelly Crescenzo, RN, BSN, CEN
Jacqueline Noll, RN, BSN, CEN
Nancy Bonalumi, RN, MS, CEN
Jill Baren, MD
Clin Pediatr Emerg Med, December, 2006, Elsevier, Inc.