Paul Sharek MD, MPH

Journal Articles

• Decreasing Handoff-Related Care Failures in Children's Hospitals. Pediatrics Bigham, M. T., Logsdon, T. R., Manicone, P. E., Landrigan, C. P., Hayes, L. W., Randall, K. H., Grover, P., Collins, S. B., Ramirez, D. E., O'Guin, C. D., Williams, C. I., Warnick, R. J., Sharek, P. J. 2014; 134 (2): e572-9

  Abstract

  Patient handoffs in health care require transfer of information, responsibility, and authority between providers. Suboptimal patient handoffs pose a serious safety risk. Studies demonstrating the impact of improved patient handoffs on care failures are lacking. The primary objective of this study was to evaluate the effect of a multihospital collaborative designed to decrease handoff-related care failures.Twenty-three children's hospitals participated in a quality improvement collaborative aimed at reducing handoff-related care failures. The improvement was guided by evidence-based recommendations regarding handoff intent and content, standardized handoff tools/methods, and clear transition of responsibility. Hospitals tailored handoff elements to locally important handoff types. Handoff-related care failures were compared between baseline and 3 intervention periods. Secondary outcomes measured compliance to specific change package elements and balancing measure of staff satisfaction.Twenty-three children's hospitals evaluated 7864 handoffs over the 12-month study period. Handoff-related care failures decreased from baseline (25.8%) to the final intervention period (7.9%) (P < .05). Significant improvement was observed in every handoff type studied. Compliance to change package elements improved (achieving a common understanding about the patient from 86% to 96% [P < .05]; clear transition of responsibility from 92% to 96% [P < .05]; and minimized interruptions and distractions from 84% to 90% [P < .05]) as did overall satisfaction with the handoff (from 55% to 70% [P < .05]).Implementation of a standardized evidence-based handoff process across 23 children's hospitals resulted in a significant decrease in handoff-related care failures, observed over all handoff types. Compliance to critical components of the handoff process improved, as did provider satisfaction.

  View details for DOI 10.1542/peds.2013-1844

  View details for PubMedID 25002665

• Performance Characteristics of a Methodology to Quantify Adverse Events over Time in Hospitalized Patients HEALTH SERVICES RESEARCH Sharek, P. J., Parry, G., Goldmann, D., Bones, K., Hackbarth, A., Resar, R., Griffin, F. A., Rhoda, D., Murphy, C., Landrigan, C. P. 2011; 46 (2): 654-678

  Abstract

  To assess the performance characteristics of the Institute for Healthcare Improvement Global Trigger Tool (GTT) to determine its reliability for tracking local and national adverse event rates.Primary data from 2008 chart reviews.A retrospective study in a stratified random sample of 10 North Carolina hospitals. Hospital-based (internal) and contract research organization-hired (external) reviewers used the GTT to identify adverse events in the same 10 randomly selected medical records per hospital in each quarter from January 2002 through December 2007.Interrater and intrarater reliability was assessed using ? statistics on 10 percent and 5 percent, respectively, of selected medical records. Additionally, experienced GTT users reviewed 10 percent of records to calculate internal and external teams' sensitivity and specificity.Eighty-eight to 98 percent of the targeted 2,400 medical records were reviewed. The reliability of the GTT to detect the presence, number, and severity of adverse events varied from ?=0.40 to 0.60. When compared with a team of experienced reviewers, the internal teams' sensitivity (49 percent) and specificity (94 percent) exceeded the external teams' (34 and 93 percent), as did their performance on all other metrics.The high specificity, moderate sensitivity, and favorable interrater and intrarater reliability of the GTT make it appropriate for tracking local and national adverse event rates. The strong performance of hospital-based reviewers supports their use in future studies.

  View details for DOI 10.1111/j.1475-6773.2010.01156.x

  View details for Web of Science ID 000287965600017

  View details for PubMedID 20722749

• Temporal Trends in Rates of Patient Harm Resulting from Medical Care. NEW ENGLAND JOURNAL OF MEDICINE Landrigan, C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Goldmann, D. A., Sharek, P. J. 2010; 363 (22): 2124-2134

  Abstract

  In the 10 years since publication of the Institute of Medicine's report To Err Is Human, extensive efforts have been undertaken to improve patient safety. The success of these efforts remains unclear.We conducted a retrospective study of a stratified random sample of 10 hospitals in North Carolina. A total of 100 admissions per quarter from January 2002 through December 2007 were reviewed in random order by teams of nurse reviewers both within the hospitals (internal reviewers) and outside the hospitals (external reviewers) with the use of the Institute for Healthcare Improvement's Global Trigger Tool for Measuring Adverse Events. Suspected harms that were identified on initial review were evaluated by two independent physician reviewers. We evaluated changes in the rates of harm, using a random-effects Poisson regression model with adjustment for hospital-level clustering, demographic characteristics of patients, hospital service, and high-risk conditions.Among 2341 admissions, internal reviewers identified 588 harms (25.1 harms per 100 admissions; 95% confidence interval [CI], 23.1 to 27.2) [corrected]. Multivariate analyses of harms identified by internal reviewers showed no significant changes in the overall rate of harms per 1000 patient-days (reduction factor, 0.99 per year; 95% CI, 0.94 to 1.04; P=0.61) or the rate of preventable harms. There was a reduction in preventable harms identified by external reviewers that did not reach statistical significance (reduction factor, 0.92; 95% CI, 0.85 to 1.00; P=0.06), with no significant change in the overall rate of harms (reduction factor, 0.98; 95% CI, 0.93 to 1.04; P=0.47).In a study of 10 North Carolina hospitals, we found that harms remain common, with little evidence of widespread improvement. Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time. (Funded by the Rx Foundation.).

  View details for Web of Science ID 000284587800007

  View details for PubMedID 21105794

• Prevalence of adverse events in pediatric intensive care units in the United States PEDIATRIC CRITICAL CARE MEDICINE Agarwal, S., Classen, D., Larsen, G., Tofil, N. M., Hayes, L. W., Sullivan, J. E., Storgion, S. A., Coopes, B. J., Craig, V., Jaderlund, C., Bisarya, H., Parast, L., Sharek, P. 2010; 11 (5): 568-578

  Abstract

  Selection of relevant patient safety interventions for the pediatric intensive care (PICU) requires identification of the types and severity of adverse events (AEs) and adverse drug events (ADEs) that occur in this setting. The study's objectives were to: 1) determine the rates of AEs/ADEs, including types, severity, and preventability, in PICU patients; 2) identify population characteristics associated with increased risk of AEs/ADEs; 3) develop and test a PICU specific trigger tool to facilitate identification of AEs/ADEs.Retrospective, cross-sectional, randomized review of 734 patient records who were discharged from 15 U.S. PICUs between September and December 2005.A novel PICU-focused trigger tool for AE/ADE detection.Sixty-two percent of PICU patients had at least one AE. A total of 1488 AEs, including 256 ADEs, were identified. This translates to a rate of 28.6 AEs and 4.9 ADEs per 100 patient-days. The most common types of AEs were catheter complications, uncontrolled pain, and endotracheal tube malposition. Ten percent of AEs were classified as life-threatening or permanent; 45% were deemed preventable. Higher adjusted rates of AEs were found in surgical patients (p = .02), patients intubated at some point during their PICU stay (p = .002), and patients who died (p < .001). Surgical patients had higher preventable adjusted AE (p = .01) and ADE rates (p = .02). The adjusted cumulative risk of an AE per PICU day was 5.3% and 1.6% for an ADE alone. There was a 4% increase in adjusted ADEs rates for every year increase in age.AEs and ADEs occur frequently in the PICU setting. These data provide areas of focus for evidence-based prevention strategies to decrease the substantial risk to this vulnerable pediatric population.

  View details for DOI 10.1097/PCC.0b013e3181d8e405

  View details for Web of Science ID 000281629300004

  View details for PubMedID 20308932

• Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System PEDIATRICS Longhurst, C. A., Parast, L., Sandborg, C. I., Widen, E., Sullivan, J., Hahn, J. S., Dawes, C. G., Sharek, P. J. 2010; 126 (1): 14-21

  Abstract

  Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates.The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital.We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80,063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17,432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation.After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008-0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%-40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.

  View details for DOI 10.1542/peds.2009-3271

  View details for Web of Science ID 000279431000003

  View details for PubMedID 20439590

• Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals PEDIATRICS Takata, G. S., Mason, W., Taketomo, C., Logsdon, T., Sharek, P. J. 2008; 121 (4): E927-E935

  Abstract

  The purposes of this study were to develop a pediatric-focused tool for adverse drug event detection and describe the incidence and characteristics of adverse drug events in children's hospitals identified by this tool.A pediatric-specific trigger tool for adverse drug event detection was developed and tested. Eighty patients from each site were randomly selected for retrospective chart review. All adverse drug events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger and the entire tool were evaluated for positive predictive value.Review of 960 randomly selected charts from 12 children's hospitals revealed 2388 triggers (2.49 per patient) and 107 unique adverse drug events. Mean adverse drug event rates were 11.1 per 100 patients, 15.7 per 1000 patient-days, and 1.23 per 1000 medication doses. The positive predictive value of the trigger tool was 3.7%. Twenty-two percent of all adverse drug events were deemed preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively. Ninety-seven percent of the identified adverse drug events resulted in mild, temporary harm. Only 3.7% of adverse drug events were identified in existing hospital-based occurrence reports. The most common adverse drug events identified were pruritus and nausea, the most common medication classes causing adverse drug events were opioid analgesics and antibiotics, and the most common stages of the medication management process associated with preventable adverse drug events were monitoring and prescribing/ordering.Adverse drug event rates in hospitalized children are substantially higher than previously described. Most adverse drug events resulted in temporary harm, and 22% were classified as preventable. Only 3.7% were identified by using traditional voluntary reporting methods. Our pediatric-focused trigger tool is effective at identifying adverse drug events in inpatient pediatric populations.

  View details for DOI 10.1542/peds.2007-1779

  View details for Web of Science ID 000254576800073

  View details for PubMedID 18381521

• Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children's hospital JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Sharek, P. J., Parast, L. M., Leong, K., Coombs, J., Earnest, K., Sullivan, J., Frankel, L. R., Roth, S. J. 2007; 298 (19): 2267-2274

  Abstract

  Introduction of a rapid response team (RRT) has been shown to decrease mortality and cardiopulmonary arrests outside of the intensive care unit (ICU) in adult inpatients. No published studies to date show significant reductions in mortality or cardiopulmonary arrests in pediatric inpatients.To determine the effect on hospital-wide mortality rates and code rates outside of the ICU setting after RRT implementation at an academic children's hospital.A cohort study design with historical controls at a 264-bed, free-standing, quaternary care academic children's hospital. Pediatric inpatients who spent at least 1 day on a medical or surgical ward between January 1, 2001, and March 31, 2007, were included. A total of 22,037 patient admissions and 102,537 patient-days were evaluated preintervention (before September 1, 2005), and 7257 patient admissions and 34,420 patient-days were evaluated postintervention (on or after September 1, 2005).The RRT included a pediatric ICU-trained fellow or attending physician, ICU nurse, ICU respiratory therapist, and nursing supervisor. This team was activated using standard criteria and was available at all times to assess, treat, and triage decompensating pediatric inpatients.Hospital-wide mortality rates and code (respiratory and cardiopulmonary arrests) rates outside of the ICU setting. All outcomes were adjusted for case mix index values.After RRT implementation, the mean monthly mortality rate decreased by 18% (1.01 to 0.83 deaths per 100 discharges; 95% confidence interval [CI], 5%-30%; P = .007), the mean monthly code rate per 1000 admissions decreased by 71.7% (2.45 to 0.69 codes per 1000 admissions), and the mean monthly code rate per 1000 patient-days decreased by 71.2% (0.52 to 0.15 codes per 1000 patient-days). The estimated code rate per 1000 admissions for the postintervention group was 0.29 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.65; P = .008), and the estimated code rate per 1000 patient-days for the postintervention group was 0.28 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.64; P = .007).Implementation of an RRT was associated with a statistically significant reduction in hospital-wide mortality rate and code rate outside of the pediatric ICU setting.

  View details for Web of Science ID 000251055900026

  View details for PubMedID 18029830

• Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs PEDIATRICS Sharek, P. J., Horbar, J. D., Mason, W., Bisarya, H., Thurm, C. W., Suresh, G., Gray, J. E., Edwards, W. H., Goldmann, D., Classen, D. 2006; 118 (4): 1332-1340

  Abstract

  Currently there are few practical methods to identify and measure harm to hospitalized children. Patients in NICUs are at high risk and warrant a detailed assessment of harm to guide patient safety efforts. The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool.A NICU-focused trigger tool for adverse event detection was developed and tested. Fifty patients from each site with a minimum 2-day NICU stay were randomly selected. All adverse events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger, and the entire tool, was evaluated for positive predictive value. Study chart reviewers, in aggregate, identified 88.0% of all potential triggers and 92.4% of all potential adverse events.Review of 749 randomly selected charts from 15 NICUs revealed 2218 triggers or 2.96 per patient, and 554 unique adverse events or 0.74 per patient. The positive predictive value of the trigger tool was 0.38. Adverse event rates were higher for patients <28 weeks' gestation and <1500 g birth weight. Fifty-six percent of all adverse events were deemed preventable; 16% could have been identified earlier, and 6% could have been mitigated more effectively. Only 8% of adverse events were identified in existing hospital-based occurrence reports. The most common adverse events identified were nosocomial infections, catheter infiltrates, and abnormal cranial imaging.Adverse event rates in the NICU setting are substantially higher than previously described. Many adverse events resulted in permanent harm and the majority were classified as preventable. Only 8% were identified using traditional voluntary reporting methods. Our NICU-focused trigger tool appears efficient and effective at identifying adverse events.

  View details for DOI 10.1542/peds.2006-0565

  View details for Web of Science ID 000240959300002

  View details for PubMedID 17015521

• Implementation Methods for Delivery Room Management: A Quality Improvement Comparison Study PEDIATRICS Lee, H. C., Powers, R. J., Bennett, M. V., Finer, N. N., Halamek, L. P., Nisbet, C., Crockett, M., Chance, K., Blackney, D., von Koehler, C., Kurtin, P., Sharek, P. J. 2014; 134 (5): E1378-E1386

  View details for DOI 10.1542/peds.2014-0863

  View details for Web of Science ID 000344385900014

• Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout BMJ QUALITY & SAFETY Sexton, J. B., Sharek, P. J., Thomas, E. J., Gould, J. B., Nisbet, C. C., Amspoker, A. B., Kowalkowski, M. A., Schwendimann, R., Profit, J. 2014; 23 (10): 814-822

  View details for DOI 10.1136/bmjqs-2013-002042

  View details for Web of Science ID 000342375400004

• Burnout in the NICU setting and its relation to safety culture BMJ QUALITY & SAFETY Profit, J., Sharek, P. J., Amspoker, A. B., Kowalkowski, M. A., Nisbet, C. C., Thomas, E. J., Chadwick, W. A., Sexton, J. B. 2014; 23 (10): 806-813

  View details for DOI 10.1136/bmjqs-2014-002831

  View details for Web of Science ID 000342375400003

• Optimizing Care of Adults With Congenital Heart Disease in a Pediatric Cardiovascular ICU Using Electronic Clinical Decision Support PEDIATRIC CRITICAL CARE MEDICINE May, L. J., Longhurst, C. A., Pageler, N. M., Wood, M. S., Sharek, P. J., Zebrack, C. M. 2014; 15 (5): 428-434

  Abstract

  The optimal location for postoperative cardiac care of adults with congenital heart disease is controversial. Some congenital heart surgeons operate on these adults in children's hospitals with postoperative care provided by pediatric critical care teams who may be unfamiliar with adult national performance measures. This study tested the hypothesis that Clinical Decision Support tools integrated into the clinical workflow would facilitate improved compliance with The Joint Commission Surgical Care Improvement Project performance measures in adults recovering from cardiac surgery in a children's hospital.Retrospective chart review comparing compliance pre- and post-Clinical Decision Support intervention for Surgical Care Improvement Project measures addressed in the critical care unit: appropriate cessation of prophylactic antibiotics; controlled blood glucose; urinary catheter removal; and reinitiation of preoperative β-blocker when indicated.Cardiovascular ICU in a quaternary care freestanding children's hospital.The cohort included 114 adults 18-70 years old recovering from cardiac surgery in our pediatric cardiovascular ICU.Clinical Decision Support tools including data-triggered alerts, smart documentation forms, and order sets with conditional logic were integrated into the workflow.Compliance with antibiotic discontinuation was 100% pre- and postintervention. Compliance rates improved for glucose control (p = 0.007) and urinary catheter removal (p = 0.05). Documentation of β-blocker therapy (nonexistent preintervention) was 100% postintervention. Composite compliance for all measures increased from 53% to 84% (p = 0.002). There were no complications related to institution of the Surgical Care Improvement Project measures. There was no in-hospital mortality.Compliance with the national adult postoperative performance measures can be excellent in a children's hospital with the help of Clinical Decision Support tools. This represents an important step toward providing high-quality care to a growing population of adults with congenital heart disease who may receive care in a pediatric center.

  View details for DOI 10.1097/PCC.0000000000000124

  View details for Web of Science ID 000337368600010

• Use of electronic medical record-enhanced checklist and electronic dashboard to decrease CLABSIs. Pediatrics Pageler, N. M., Longhurst, C. A., Wood, M., Cornfield, D. N., Suermondt, J., Sharek, P. J., Franzon, D. 2014; 133 (3): e738-46

  Abstract

  We hypothesized that a checklist enhanced by the electronic medical record and a unit-wide dashboard would improve compliance with an evidence-based, pediatric-specific catheter care bundle and decrease central line-associated bloodstream infections (CLABSI).We performed a cohort study with historical controls that included all patients with a central venous catheter in a 24-bed PICU in an academic children's hospital. Postintervention CLABSI rates, compliance with bundle elements, and staff perceptions of communication were evaluated and compared with preintervention data.CLABSI rates decreased from 2.6 CLABSIs per 1000 line-days before intervention to 0.7 CLABSIs per 1000 line-days after intervention. Analysis of specific bundle elements demonstrated increased daily documentation of line necessity from 30% to 73% (P < .001), increased compliance with dressing changes from 87% to 90% (P = .003), increased compliance with cap changes from 87% to 93% (P < .001), increased compliance with port needle changes from 69% to 95% (P < .001), but decreased compliance with insertion bundle documentation from 67% to 62% (P = .001). Changes in the care plan were made during review of the electronic medical record checklist on 39% of patient rounds episodes.Use of an electronic medical record-enhanced CLABSI prevention checklist coupled with a unit-wide real-time display of adherence was associated with increased compliance with evidence-based catheter care and sustained decrease in CLABSI rates. These data underscore the potential for computerized interventions to promote compliance with proven best practices and prevent patient harm.

  View details for DOI 10.1542/peds.2013-2249

  View details for PubMedID 24567021

• Use of Electronic Medical Record-Enhanced Checklist and Electronic Dashboard to Decrease CLABSIs PEDIATRICS Pageler, N. M., Longhurst, C. A., Wood, M., Cornfield, D. N., Suermondt, J., Sharek, P. J., Franzon, D. 2014; 133 (3): E738-E746

  View details for DOI 10.1542/peds.2013-2249

  View details for Web of Science ID 000335330700058

• Exemplar Pediatric Collaborative Improvement Networks: Achieving Results PEDIATRICS Billett, A. L., Colletti, R. B., Mandel, K. E., Miller, M., Muething, S. E., Sharek, P. J., Lannon, C. M. 2013; 131: S196-S203

  Abstract

  A number of pediatric collaborative improvement networks have demonstrated improved care and outcomes for children. Regionally, Cincinnati Children's Hospital Medical Center Physician Hospital Organization has sustained key asthma processes, substantially increased the percentage of their asthma population receiving "perfect care," and implemented an innovative pay-for-performance program with a large commercial payor based on asthma performance measures. The California Perinatal Quality Care Collaborative uses its outcomes database to improve care for infants in California NICUs. It has achieved reductions in central line-associated blood stream infections (CLABSI), increased breast-milk feeding rates at hospital discharge, and is now working to improve delivery room management. Solutions for Patient Safety (SPS) has achieved significant improvements in adverse drug events and surgical site infections across all 8 Ohio children's hospitals, with 7700 fewer children harmed and >$11.8 million in avoided costs. SPS is now expanding nationally, aiming to eliminate all events of serious harm at children's hospitals. National collaborative networks include ImproveCareNow, which aims to improve care and outcomes for children with inflammatory bowel disease. Reliable adherence to Model Care Guidelines has produced improved remission rates without using new medications and a significant increase in the proportion of Crohn disease patients not taking prednisone. Data-driven collaboratives of the Children's Hospital Association Quality Transformation Network initially focused on CLABSI in PICUs. By September 2011, they had prevented an estimated 2964 CLABSI, saving 355 lives and $103,722,423. Subsequent improvement efforts include CLABSI reductions in additional settings and populations.

  View details for DOI 10.1542/peds.2012-3786F

  View details for Web of Science ID 000321674900003

  View details for PubMedID 23729760

• A Clinical Case of Electronic Health Record Drug Alert Fatigue: Consequences for Patient Outcome PEDIATRICS Carspecken, W., Sharek, P. J., Longhurst, C., Pageler, N. M. 2013; 131 (6): E1970-E1973

  View details for DOI 10.1542/peds.2012-3252

  View details for Web of Science ID 000322840200033

• A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Pediatrics Carspecken, C. W., Sharek, P. J., Longhurst, C., Pageler, N. M. 2013; 131 (6): e1970-3

  Abstract

  Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non-evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital's system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.

  View details for DOI 10.1542/peds.2012-3252

  View details for PubMedID 23713099

• A Quality Improvement Project to Increase Breast Milk Use in Very Low Birth Weight Infants PEDIATRICS Lee, H. C., Kurtin, P. S., Wight, N. E., Chance, K., Cucinotta-Fobes, T., Hanson-Timpson, T. A., Nisbet, C. C., Rhine, W. D., Risingsun, K., Wood, M., Danielsen, B. H., Sharek, P. J. 2012; 130 (6): E1679-E1687

  Abstract

  To evaluate a multihospital collaborative designed to increase breast milk feeding in premature infants.Eleven NICUs in the California Perinatal Quality of Care Collaborative participated in an Institute for Healthcare Improvement-style collaborative to increase NICU breast milk feeding rates. Multiple interventions were recommended with participating sites implementing a self-selected combination of these interventions. Breast milk feeding rates were compared between baseline (October 2008-September 2009), implementation (October 2009-September 2010), and sustainability periods (October 2010-March 2011). Secondary outcome measures included necrotizing enterocolitis (NEC) rates and lengths of stay. California Perinatal Quality of Care Collaborative hospitals not participating in the project served as a control population.The breast milk feeding rate in the intervention sites improved from baseline (54.6%) to intervention period (61.7%; P = .005) with sustained improvement over 6 months postintervention (64.0%; P = .003). NEC rates decreased from baseline (7.0%) to intervention period (4.3%; P = .022) to sustainability period (2.4%; P < .0001). Length of stay increased during the intervention but returned to baseline levels in the sustainability period. Control hospitals had higher rates of breast milk feeding at baseline (64.2% control vs 54.6% participants, P < .0001), but over the course of the implementation (65.7% vs 61.7%, P = .049) and sustainability periods (67.7% vs 64.0%, P = .199), participants improved to similar rates as the control group.Implementation of a breast milk/nutrition change package by an 11-site collaborative resulted in an increase in breast milk feeding and decrease in NEC that was sustained over an 18-month period.

  View details for DOI 10.1542/peds.2012-0547

  View details for Web of Science ID 000314802000033

  View details for PubMedID 23129071

• Reducing Mortality Related to Adverse Events in Children PEDIATRIC CLINICS OF NORTH AMERICA Shin, A. Y., Longhurst, C. A., Sharek, P. J. 2012; 59 (6): 1293-?

  Abstract

  Since the launch of the 100,000 Lives Campaign by the Institute for Healthcare Improvement (IHI), preventing medical adverse events to reduce avoidable mortality has emerged as a central focus for health care providers, institutions, regulators, insurance companies, and patients. Evidence-based interventions targeting the 6 interventions in the campaign have been associated with a reduction in preventable hospital deaths in the United States. The generalizability of the IHI's campaign to the pediatric population is only partly applicable. Pediatric experiences with rapid response teams and preventing central-line infections parallel the published experience of adults, with promise to significantly reduce preventable pediatric mortality.

  View details for DOI 10.1016/j.pcl.2012.09.002

  View details for Web of Science ID 000312618600007

  View details for PubMedID 23116526

• Integrating the home management plan of care for children with asthma into an electronic medical record. Joint Commission journal on quality and patient safety / Joint Commission Resources Patel, S. J., Longhurst, C. A., Lin, A., Garrett, L., Gillette-Arroyo, J., Mark, J. D., Wood, M. S., Sharek, P. J. 2012; 38 (8): 359-365

  Abstract

  Asthma exacerbation is one of the most common causes for pediatric hospitalization. One of the three Joint Commission quality measures--which has proven the most challenging--addresses the provision of a home management plan of care (HMPC) for discharge of pediatric inpatients with a primary diagnosis of asthma. A user-friendly electronic medical record (EMR)-generated HMPC was developed and implemented at Lucile Packard Children's Hospital (LPCH) Palo Alto, California, an HPMC needed to be completed before entry of an inpatient discharge order.A cohort study using historical controls was conducted in 2010-2011. Patients were eligible to receive an HMPC if they were between the ages of 2 and 17 years old at discharge, had a length of stay < 120 days, were not enrolled in clinical trials, and had the primary discharge diagnosis of asthma. These patients were identified by the EMR if this diagnosis was listed in the diagnosis list or problem list or if the asthma admit/discharge order set was initiated.Compliance with the HMPC increased from 65.3% for the 39 months (April 1, 2007-June 30, 2010) before integration of the HMPC into EMR to 93.7% for the 18 months after integration (July 1, 2010, through December 31, 2011); p < .0001. Users of the EMR-integrated HMPC found it to be significantly easier to complete, less time-consuming, and less prone to potential errors or omission.Lessons learned at LPCH included the need for a continuous surveillance and improvement model, which resulted in several iterations of the HMPC; the importance of soliciting user input, which resulted in improvements in work flow; and consistent support from the quality management and information technology departments, which are crucial to eliminating barriers and facilitating improvement.

  View details for PubMedID 22946253

• The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety. AHRQ WebM&M : morbidity & mortality rounds on the Web Sharek, P. J. 2012; 2012 (5)

  View details for PubMedID 23667349

• Rapid Response Team Implementation in a Children's Hospital ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Sharek, P. J., Parast, L. M., Roth, S. J. 2011; 165 (12): 1139-1139

  View details for Web of Science ID 000297638100016

  View details for PubMedID 22147784

• Impact of electronic medical record integration of a handoff tool on sign-out in a newborn intensive care unit JOURNAL OF PERINATOLOGY Palma, J. P., Sharek, P. J., Longhurst, C. A. 2011; 31 (5): 311-317

  Abstract

  Objective:To evaluate the impact of integrating a handoff tool into the electronic medical record (EMR) on sign-out accuracy, satisfaction and workflow in a neonatal intensive care unit (NICU).Study Design:Prospective surveys of neonatal care providers in an academic children's hospital 1 month before and 6 months following EMR integration of a standalone Microsoft Access neonatal handoff tool.Result:Providers perceived sign-out information to be somewhat or very accurate at a rate of 78% with the standalone handoff tool and 91% with the EMR-integrated tool (P < 0.01). Before integration of neonatal sign-out into the EMR, 35% of providers were satisfied with the process of updating sign-out information and 71% were satisfied with the printed sign-out document; following EMR integration, 92% of providers were satisfied with the process of updating sign-out information (P < 0.01) and 98% were satisfied with the printed sign-out document (P<0.01). Neonatal care providers reported spending a median of 11 to 15 min/day updating the standalone sign-out and 16 to 20 min/day updating the EMR-integrated sign-out (P = 0.026). The median percentage of total sign-out preparation time dedicated to transcribing information from the EMR was 25 to 49% before and <25% after EMR integration of the handoff tool (P < 0.01).Conclusion:Integration of a NICU-specific handoff tool into an EMR resulted in improvements in perceived sign-out accuracy, provider satisfaction and at least one aspect of workflow.

  View details for DOI 10.1038/jp.2010.202

  View details for Web of Science ID 000289982300003

  View details for PubMedID 21273990

• Neonatal Informatics: Computerized Physician Order Entry. NeoReviews Palma, J. P., Sharek, P. J., Classen, D. C., Longhurst, C. A. 2011; 12: 393-396

  Abstract

  Computerized physician order entry (CPOE) is the feature of electronic medical record (EMR) implementation that arguably offers the greatest quality and patient safety benefits. The gains are potentially greater for critically ill neonates, but the effect of CPOE on quality and safety is dependent upon local implementation decisions. OBJECTIVES: After completing this article, readers should be able to: Define the basic aspects of CPOE and clinical decision support (CDS) systems.Describe the potential benefits of implementing CPOE associated with CDS in a neonatal intensive care unit (NICU).

  View details for PubMedID 21804768

• NICU Practices and Outcomes Associated With 9 Years of Quality Improvement Collaboratives PEDIATRICS Payne, N. R., Finkelstein, M. J., Liu, M., Kaempf, J. W., Sharek, P. J., Olsen, S. 2010; 125 (3): 437-446

  Abstract

  Quality improvement collaboratives (QICs) can improve short-term outcomes, but few have examined their long-term results. This study evaluated the changes in treatment practices and outcomes associated with participation in multiple sequential QICs.This retrospective, 9-year, pre-post study of very low birth weight infants, we assessed treatment and outcomes from the 8 NICUs of the Reduce Lung Injury (ReLI) group of a QIC sponsored by the Vermont Oxford Network (VON). We analyzed data from 1998 (pre-ReLI), 2001 (last ReLI year), and 2006 (5 years after ReLI) by using univariate and multiple regression.A total of 4065 very low birth weight infants were treated in ReLI NICUs in 1998, 2001, and 2006. From 1998 to 2006, the ReLI group decreased delivery room intubation (70% vs 52%; adjusted odds ratio [aOR]: 0.2 [95% confidence interval (CI): 0.2-0.3]; P < .001), conventional ventilation (75% vs 62%; aOR: 0.3 [95% CI: 0.2-0.4]; P < .001), and postnatal steroids for BPD (35% vs 10%; aOR: 0.09 [95% CI: 0.07-0.1]; P < .001). They increased the use of nasal continuous positive airway pressure (57% vs 78%; aOR: 3.3 [95% CI: 2.7-3.9]; P < .001). BPD-free survival remained unchanged (68% vs 66%; aOR: 0.9 [95% CI: 0.7-1.1]; P = .16), the BPD rate increased (25% vs 29%; aOR: 1.3 [95% CI: 1.1-1.6]; P = .017), survival to discharge increased (90% vs 93%; aOR: 1.5 [95% CI: 1.1-2.2]; P < .001), and nosocomial infections decreased (18% vs 15%; aOR: 0.8 [95% CI: 0.6-0.99]; P = .045).Participation in VON-sponsored QICs was associated with sustained implementation of potentially better respiratory practices, increased survival, and reduced nosocomial infections. The BPD-free survival rate did not change, and the BPD rate increased. Implemented changes endured for at least 5 years after the QIC.

  View details for DOI 10.1542/peds.2009-1272

  View details for Web of Science ID 000275945700004

  View details for PubMedID 20123773

• Improved physician work flow after integrating sign-out notes into the electronic medical record. Joint Commission journal on quality and patient safety / Joint Commission Resources Bernstein, J. A., Imler, D. L., Sharek, P., Longhurst, C. A. 2010; 36 (2): 72-78

  Abstract

  In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed.A printable sign-out report was implemented within the EMR system at a tertiary academic children's hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey.The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process.EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.

  View details for PubMedID 20180439

• Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion TRANSFUSION Goodnough, L. T., Viele, M., Fontaine, M. J., Jurado, C., Stone, N., Quach, P., Chua, L., Chin, M., Scott, R., Tokareva, I., Tabb, K., Sharek, P. J. 2009; 49 (7): 1321-1328

  Abstract

  This study presents our implementation of a two-specimen requirement with no prior record of ABO/Rh to verify patients' blood type before transfusion.Blood type verification was introduced, discussed, approved, and implemented over a 12-month period (May 2007 to May 2008). Potential barriers and impact on benchmark indicators were identified and tracked.Inpatient identification and/or specimen labeling for nursing and laboratory phlebotomists baseline corrected error rates were 1:467 and 1:5555, respectively. This study therefore sought and obtained approval to initiate a new policy of blood type verification before blood transfusion. Compliance in turnaround time (TAT) before and after implementation for completion of STAT type and screen/crossmatch within 60 minutes worsened marginally, from 90% to 80%. The impact on use of O-, uncrossmatched blood was found to be manageable. Seven (of 25 total) recorded electronic complaints were received after implementation. The corrected error rate for nurse phlebotomy draws after implementation was 1:630.Despite the lack of an instigating event, verification of blood type before blood transfusion was successfully implemented. An impact on resources and benchmark indicators such as TAT can be anticipated and managed. Further process improvement efforts will be needed to ensure safety (e.g., at time of blood transfusion) for patients receiving blood transfusions. ABO/Rh verification may be necessary even after future implementation of bar coding and/or RFID chips, because human errors continue to occur even with systems improvements.

  View details for DOI 10.1111/j.1537-2995.2009.02157.x

  View details for Web of Science ID 000267715300010

  View details for PubMedID 19389026

• An intervention to decrease narcotic-related adverse drug events in children's hospitals PEDIATRICS Sharek, P. J., McClead, R. E., Taketomo, C., Luria, J. W., Takata, G. S., Walti, B., Tanski, M., Nelson, C., Logsdon, T. R., Thurm, C., Federico, F. 2008; 122 (4): E861-E866

  Abstract

  Narcotic-related adverse drug events are the most common adverse drug events in hospitalized children. Despite multiple published studies describing interventions that decrease adverse drug events from narcotics, large-scale collaborative quality improvement efforts to address narcotic-related adverse drug events in pediatrics have not been described. The purpose of this study was to evaluate collaborative-wide narcotic-related adverse drug event rates after a collection of expert panel-defined best practices was implemented.All 42 children's hospitals in the Child Health Corporation of America were invited to participate in the Institute for Healthcare Improvement-style quality improvement collaborative aimed at reducing narcotic-related adverse drug events. A collection of interventions known or suspected to reduce narcotic-related adverse drug events was recommended by an expert panel, with each site implementing >or=1 of these best practices on the basis of local need. Narcotic-related adverse drug event rates were compared between the baseline (December 1, 2004, to March 31, 2005) and postimplementation periods (January 1, 2006, to March 31, 2006) after an a priori-defined intervention ramp-up time (April 1, 2005, and December 31, 2005). Secondary outcome measures included constipation rates and narcotic-related automated drug-dispensing-device override percentages.Median narcotic-related adverse drug event rates decreased 67% between the baseline and postimplementation time frames across the 14-site collaborative. Constipation rates decreased 68.9%, and automated drug-dispensing-device overrides decreased from 10.18% to 5.91% of all narcotic doses administered.Implementation of >or=1 expert panel-recommended interventions at each participating site resulted in a significant decrease in narcotic-related adverse drug events, constipation, and automated drug-dispensing-device overrides in a 12-month, 14-site children's hospital quality collaborative.

  View details for DOI 10.1542/peds.2008-1011

  View details for Web of Science ID 000259812600053

  View details for PubMedID 18829784

• Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety PEDIATRICS Landrigan, C. P., Fahrenkopf, A. M., Lewin, D., Sharek, P. J., Barger, L. K., Eisner, M., Edwards, S., Chiang, V. W., Wiedermann, B. L., Sectish, T. C. 2008; 122 (2): 250-258

  Abstract

  To mitigate the risks of fatigue-related medical errors, the Accreditation Council for Graduate Medical Education introduced work hour limits for resident physicians in 2003. Our goal was to determine whether work hours, sleep, and safety changed after implementation of the Accreditation Council for Graduate Medical Education standards.We conducted a prospective cohort study in which residents from 3 large pediatric training programs provided daily reports of work hours and sleep. In addition, they completed reports of near-miss and actual motor vehicle crashes, occupational exposures, self-reported medical errors, and ratings of educational experience. They were screened for depression and burnout. Concurrently, at 2 of the centers, data on medication errors were collected prospectively by using an established active surveillance method.A total of 220 residents provided 6007 daily reports of their work hours and sleep, and 16 158 medication orders were reviewed. Although scheduling changes were made in each program to accommodate the standards, 24- to 30-hour shifts remained common, and the frequency of residents' call remained largely unchanged. There was no change in residents' measured total work hours or sleep hours. There was no change in the overall rate of medication errors, and there was a borderline increase in the rate of resident physician ordering errors, from 1.06 to 1.38 errors per 100 patient-days. Rates of motor vehicle crashes, occupational exposures, depression, and self-reported medical errors and overall ratings of work and educational experiences did not change. The mean length of extended-duration (on-call) shifts decreased 2.7% to 28.5 hours, and rates of resident burnout decreased significantly (from 75.4% to 57.0%).Total hours of work and sleep did not change after implementation of the duty hour standards. Although fewer residents were burned out, rates of medication errors, resident depression, and resident injuries and educational ratings did not improve.

  View details for DOI 10.1542/peds.2007-2306

  View details for Web of Science ID 000258142500004

  View details for PubMedID 18676540

• Improving communication in a pediatric intensive care unit using daily patient goal sheets JOURNAL OF CRITICAL CARE Agarwal, S., Frankel, L., Tourner, S., McMillan, A., Sharek, P. J. 2008; 23 (2): 227-235

  Abstract

  The aim of the study was to determine if a pediatric intensive care unit (PICU) daily patient goal sheet would improve communication between health care providers and decrease length of stay (LOS).We evaluated a daily patient goal sheet's impact on questionnaire-based measures of effectiveness of communication, nurses' knowledge of physicians in charge, and on LOS in the PICU.Four hundred nineteen questionnaires were completed by nurses and physicians before goal sheet implementation and 387 after implementation. Nurses and physicians perceived an improved understanding of patient care goals (P < .001), reported increased comfort in explaining patient care goals to parents (P < .001), and listed a higher number of patient care goals after goal sheet implementation (P < .01). Nurses identified the patient's attending physician and fellow with increased accuracy after goal sheet implementation (P < .001). Median PICU LOS was unchanged; however, mean LOS trended toward a reduction after goal sheet implementation (4.1 vs 3.7 days, P = .36). Seventy-six percent of respondents found the goal sheets helpful.Using a PICU daily patient goal sheet can improve communication between health care providers, help nurses identify the in-charge physicians, and be helpful for patient care. By explicitly documenting patient care goals, there is enhanced clarity of patient care plans between health care providers.

  View details for DOI 10.1016/j.jcrc.2007.07.001

  View details for Web of Science ID 000256890800013

  View details for PubMedID 18538216

• Neonatal heparin overdose-a multidisciplinary team approach to medication error prevention. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG Arimura, J., Poole, R. L., Jeng, M., Rhine, W., Sharek, P. 2008; 13 (2): 96-98

  Abstract

  Despite the efforts of many hospitals, system failures can result in medication errors that may be life threatening. During 2006 and 2007, nine neonates received potentially fatal doses of heparin. This paper will review contributing factors to the heparin medication errors and ways to minimize the risk of heparin overdose.

  View details for DOI 10.5863/1551-6776-13.2.96

  View details for PubMedID 23055872

• Rates of medication errors among depressed and burnt out residents: prospective cohort study BRITISH MEDICAL JOURNAL Fahrenkopf, A. M., Sectish, T. C., Barger, L. K., Sharek, P. J., Lewin, D., Chiang, V. W., Edwards, S., Wiedermann, B. L., Landrigan, C. P. 2008; 336 (7642): 488-491

  Abstract

  To determine the prevalence of depression and burnout among residents in paediatrics and to establish if a relation exists between these disorders and medication errors.Prospective cohort study.Three urban freestanding children's hospitals in the United States.123 residents in three paediatric residency programmes.Prevalence of depression using the Harvard national depression screening day scale, burnout using the Maslach burnout inventory, and rate of medication errors per resident month.24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed: 1.55 (95% confidence interval 0.57 to 4.22) compared with 0.25 (0.14 to 0.46, P<0.001). Burnt out residents and non-burnt out residents made similar rates of errors per resident month: 0.45 (0.20 to 0.98) compared with 0.53 (0.21 to 1.33, P=0.2).Depression and burnout are major problems among residents in paediatrics. Depressed residents made significantly more medical errors than their non-depressed peers; however, burnout did not seem to correlate with an increased rate of medical errors.

  View details for DOI 10.1136/bmj.39469.763218.BE

  View details for Web of Science ID 000253997500041

  View details for PubMedID 18258931

• The use of telemedicine access to schools to facilitate expert assessment of children with asthma. International journal of telemedicine and applications Bergman, D. A., Sharek, P. J., Ekegren, K., Thyne, S., Mayer, M., Saunders, M. 2008: 159276-?

  Abstract

  Research has shown that access to an asthma specialist improves asthma outcomes. We hypothesized that we could improve access to expert asthma care through a telemedicine link between an asthma specialist and a school-based asthma program. We conducted a prospective cohort study in 3 urban schools to ascertain the feasibility of using an asthma-focused telemedicine solution. Each subject was seen by an asthma expert at 0, 8, and 32 weeks. The assessment and recommendations for care were sent to the primary care physician (PCP) and parents were told to contact their physician for follow-up care. Eighty three subjects participated in the study. Subjects experienced improvement (P < .05) in family social activities and the number of asthma attacks. Ninety four percent of subjects rated the program as good or excellent. This study demonstrates the feasibility and acceptance of a school-based asthma program using a telemedicine link to an asthma specialist.

  View details for DOI 10.1155/2008/159276

  View details for PubMedID 18369409

• Best practice implementation: lessons learned from 20 partnerships. Joint Commission journal on quality and patient safety / Joint Commission Resources Sharek, P. J., Mullican, C., Lavanderos, A., Palmer, C., Snow, V., Kmetik, K., Antman, M., Knutson, D., Dembry, L. M. 2007; 33 (12): 16-26

  Abstract

  Partnerships can facilitate effective implementation of best practices, but literature describing effective and ineffective strategies to address barriers to implementation in partnerships is lacking.Principal investigators (PIs) were surveyed to identify barriers to best practice implementation, rank their significance, and articulate the success and failure of solutions attempted.The top four categories of barriers to implementation were partnership challenges, practitioner/local organization variables, time frame challenges, and financial concerns. Ninety-eight effective and 38 ineffective solutions used to overcome these barriers were identified. The most common categories of successful solutions were flexibility of interventions to align with unique local characteristics, schedules, and budgets (36.7% of listed successful solutions); communication strategies that emphasize frequent bidirectional information exchange in person (26.5%); and thoughtful use of personnel emphasizing sites' senior leadership and centralized quality and analytic content expertise (16.3%).Despite substantial partnership diversity, consistent themes related to barriers to implementation and solutions to these barriers emerged. The successful and unsuccessful solutions provided should be proactively assessed to enhance the likelihood of future partnership success.

  View details for PubMedID 18277636

• Simulation-based medical error disclosure training for pediatric healthcare professionals. Journal for healthcare quality : official publication of the National Association for Healthcare Quality Wayman, K. I., Yaeger, K. A., Sharek, P. J., Trotter, S., Wise, L., Flora, J. A., Halamek, L. P. 2007; 29 (4): 12-19

  Abstract

  Ethical and regulatory guidelines recommend disclosure of medical errors to patients and families. Yet few studies examine how to effectively train healthcare professionals to deliver communications about adverse events to family members of affected pediatric patients. This pilot study uses a preintervention-postintervention study design to investigate the effects of medical error disclosure training in a simulated setting for pediatric oncology nurses (N=16). The results of a paired t test showed statistically significant increases in nurses' communication self-efficacy to carry out medical disclosure (t = 6.68, p < .001). Ratings of setting "realism" and simulation effectiveness were high (21 out of 25 composite score). Findings provide preliminary support for further research on simulation-based disclosure training for healthcare professionals.

  View details for PubMedID 17849675

• The incidence of adverse events and medical error in pediatrics PEDIATRIC CLINICS OF NORTH AMERICA Sharek, P. J., Classen, D. 2006; 53 (6): 1067-?

  Abstract

  In its 2000 report, To Err is Human, the Institute of Medicine concluded that between 44,000 and 98,000 deaths per year occur in United States hospitals as a result of error. These data have resulted in calls for further research, regulatory interventions, third-party payer involvement, and health care organization initiatives to improve this situation. Studies of pediatric inpatients suggest that medication-related harm occurs at a rate as high as 11.1 per 100 admissions, and hospital-related harm occurs in high risk neonatal ICUs at a rate of 74 per 100 admissions. This article discusses differences between error and harm, methods used to measure harm, and available evidence that identifies the incidence of adverse events in pediatric inpatients and outpatients.

  View details for DOI 10.1016/j.pcl.2006.09.011

  View details for Web of Science ID 000243305100003

  View details for PubMedID 17126682

• Evaluation and development of potentially better practices to improve pain management of neonates PEDIATRICS Sharek, P. J., Powers, R., Koehn, A., Anand, K. J. 2006; 118: S78-S86

  Abstract

  Despite increased knowledge, improved options, and regulatory mandates, pain management of neonates remains inadequate, promoted by the ineffective translation of research data into clinical practice. The Neonatal Intensive Care Quality Improvement Collaborative 2002 was created to provide participating NICUs the tools necessary to translate research, related to prevention and treatment of neonatal pain, into practice. The objective for this study was to use proven quality improvement methods to develop a process to improve neonatal pain management collaboratively.Twelve members of the Neonatal Intensive Care Quality Improvement Collaborative 2002 formed an exploratory group to improve neonatal pain management. The exploratory group established group and site-specific goals and outcome measures for this project. Group members crafted a list of potentially better practices on the basis of the available literature, encouraged implementation of the potentially better practices at individual sites, developed a database for sharing information, and measured baseline outcomes.The goal "improve the assessment and management of infants experiencing pain in the NICU" was established. In addition, each site within the group identified local goals for improvement in neonatal pain management. Data from 7 categories of neonates (N = 277) were collected within 48 hours of NICU admission to establish baseline data for clinical practices. Ten potentially better practices were developed for prioritized pain conditions, and 61 potentially better practices were newly implemented at the 12 participating sites. Various methods were used for pain assessment at the participating centers. At baseline, heel sticks were used more frequently than peripheral intravenous insertions or venipunctures, with substantial variability in the number of avoidable procedures between centers. Pain was assessed in only 17% of procedures, and analgesic interventions were performed in 19% of the procedures at baseline.Collaborative use of quality improvement methods resulted in the creation of self-directed, efficient, and effective processes to improve neonatal pain management. Group establishment of potentially better practices, collective and site-specific goals, and extensive baseline data resulted in accelerated implementation of clinical practices that would not likely occur outside a collaborative setting.

  View details for DOI 10.1542/peds.2006-0913D

  View details for Web of Science ID 000243201000004

  View details for PubMedID 17079627

• Implementation and case-study results of potentially better practices to improve pain management of neonates PEDIATRICS Dunbar, A. E., Sharek, P. J., Mickas, N. A., Coker, K. L., Duncan, J., McLendon, D., Pagano, C., Puthoff, T. D., Reynolds, N. L., Powers, R. J., Johnston, C. C. 2006; 118: S87-S94

  Abstract

  Collaborative quality improvement techniques were used to facilitate local quality improvement in the management of pain in infants. Several case studies are presented to highlight this process.Twelve NICUs in the Neonatal Intensive Care Quality Improvement Collaborative 2002 focused on improving neonatal pain management and sedation practices. These centers developed and implemented evidence-based potentially better practices for pain management and sedation in neonates. The group introduced changes through plan-do-study-act cycles and tracked performance measures throughout the process.Strategies for implementing potentially better practices varied between centers on the basis of local characteristics. Individual centers identified barriers to implementation, developed tools for improvement, and shared their experience with the collaborative. Baseline data from the 12 sites revealed substantial opportunities for improved pain management, and local potentially better practice implementation resulted in measurable improvements in pain management at participating centers.The use of collaborative quality improvement techniques enhanced local quality improvement efforts and resulted in effective implementation of potentially better practices at participating centers.

  View details for DOI 10.1542/peds.2006-0913E

  View details for Web of Science ID 000243201000005

  View details for PubMedID 17079628

• Perceived increase in mortality after process and policy changes implemented with computerized physician order entry PEDIATRICS Longhurst, C., Sharek, P., Hahn, J., Sullivan, J., Classen, D. 2006; 117 (4): 1450-1451

  View details for DOI 10.1542/peds.2005-3048

  View details for Web of Science ID 000236540500088

  View details for PubMedID 16585351

• Improved pain management in pediatric postoperative liver transplant patients using parental education and non-pharmacologic interventions PEDIATRIC TRANSPLANTATION Sharek, P. J., Wayman, K., Lin, E., Strichartz, D., Sentivany-Collins, S., Good, J., Esquivel, C., Brown, M., Cox, K. 2006; 10 (2): 172-177

  Abstract

  A pain management intervention, consisting of pretransplant parental education and support, pre- and postoperative behavioral pediatrics consultation, postoperative physical and occupational therapy consultation, and implementation of non-pharmacologic pain management strategies, was introduced to all pediatrics patients receiving liver transplants at Lucile Packard Children's Hospital beginning August 2001. Children receiving transplants pre-intervention (May, 2000 to February, 2001) and post-intervention (August, 2001 to March, 2002) were compared using pain scores, parent perception of pain ratings, length of stay, ventilator days, total cost, and opioid use. A total of 27 children were evaluated (13 historical control, 14 intervention). The two populations did not differ on age at transplant (mean age 53.8 vs. 63.6 months), sex (46.1% vs. 50% male), ethnicity (53.8% vs. 57.1% white, non-Hispanic) weight at transplant (17.5 vs. 24.7 kg), percent with biliary atresia as the primary reason for transplant (42.9% vs. 69.2%), percent with status 1 transplant listing score (38.5% vs. 50.0%), or public insurance status (30.8 vs. 57.2% with Medicaid). No differences were found in mean pediatric intensive care unit (PICU) postoperative length of stay (6.7 vs. 5.3 days), total postoperative length of stay (17.5 vs. 17.5 days), total inpatient length of stay (27.0 vs. 24.4 days), time to extubation (30 vs. 24.3 h), total cost (dollar 147,983 vs. dollar 157,882) or opioid use through postoperative day (POD) 6 (0.24 vs. 0.25 mg/kg/day morphine equivalent). A decrease in mean pain score between POD 0 and 6 (2.82 vs. 2.12; p = 0.047), a decrease in mean parental pain perception score (3.1 vs. 2.1; p = 0.001), and an increase in number of pain assessments per 12 h shift (3.43 vs. 6.79; p < 0.005) were seen. A comprehensive non-pharmacologic postoperative pain management program in children receiving a liver transplant was associated with decreased pain scores, improved parent perception of pain, and an increased number of pain assessments per 12 h shift. No increases in lengths of stay (PICU, postoperative, total), time to extubation, or total cost were found.

  View details for DOI 10.1111/j.1399-3046.2005.00438.x

  View details for Web of Science ID 000236026400011

  View details for PubMedID 16573603

• Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: A randomized, controlled, crossover trial involving simulated resuscitation scenarios PEDIATRICS Agarwal, S., Swanson, S., Murphy, A., Yaeger, K., Sharek, P., Halamek, L. P. 2005; 116 (3): E326-E333

  Abstract

  Access to resuscitation equipment is a critical component in delivering optimal care in pediatric arrest situations. Historically, children's hospitals and clinics have used a standard pediatric resuscitation cart ("standard cart") in which drawers are organized by intervention (eg, intubation module, intravenous module), requiring multiple drawers to be opened during a code. Many emergency departments, however, use a pediatric resuscitation cart based on the Broselow tape ("Broselow cart") in which each drawer is color coded and organized by patient length and weight ranges; each drawer contains all necessary equipment for resuscitation of a patient in that specific length/weight range. A literature review has revealed no studies examining the utility of either cart.To compare which resuscitation cart organization (standard versus Broselow) allows for faster access to equipment, more accurate selection of appropriately sized equipment, and better user satisfaction. Methodology. We performed a prospective, randomized, controlled, crossover trial in which 21 pediatric health care providers were assigned the role of obtaining the appropriate equipment during 2 standardized, simulated codes alternately using either a standard or Broselow cart. Time to and accuracy of the selection of appropriate medical equipment along with posttesting satisfaction were measured. All simulations were performed in the Center for Advanced Pediatric Education at Stanford University Medical Center (Stanford, CA), a training facility designed to replicate the real medical environment with the technology to allow for videotaping of scenarios.Of the 21 subjects, 62% found the Broselow cart "easy" or "very easy" to use versus 33% for the standard cart. Of the 21 subjects, 67% preferred the Broselow cart, 10% preferred the standard cart, and 23% indicated no preference. Intubation supplies and nasogastric tubes were found significantly faster when using the Broselow cart (mean time: 29.1 and 20 seconds, respectively) versus the standard cart (mean time: 38.7 and 38.2 seconds, respectively). Correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart. Ten percent of the subjects had prior experience with the Broselow cart versus 62% having experience with the standard cart.Despite less prior experience with the Broselow cart, subjects in this study found it easier to use and preferred it over the standard cart. In addition, subjects located intubation equipment and nasogastric tubes significantly faster when using the Broselow cart, and correct equipment was provided significantly more often with the Broselow cart. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation carts after the Broselow cart to enhance provider confidence and patient safety.

  View details for DOI 10.1542/peds.2005-0320

  View details for Web of Science ID 000231576600001

  View details for PubMedID 16061568

• Effectiveness of a multicomponent self-management program in at-risk, school-aged children with asthma ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Shames, R. S., Sharek, P., Mayer, M., Robinson, T. N., Hoyte, E. G., Gonzalez-Hensley, F., Bergman, D. A., Umetsu, D. T. 2004; 92 (6): 611-618

  Abstract

  Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care.To determine the effectiveness of an asthma education video game in reducing morbidity among high-risk, school-aged children with asthma.We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study.Compared with controls, the intervention group had significant improvements in the physical domain (P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain (P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child (P = .02 at 8 weeks) and parent (P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables.A multicomponent educational, behavioral, and medical intervention targeted at high-risk, inner-city children with asthma can improve asthma knowledge and quality of life.

  View details for Web of Science ID 000222121500007

  View details for PubMedID 15237762

• Evaluation and development of potentially better practices to prevent chronic lung disease and reduce lung injury in neonates PEDIATRICS Sharek, P. J., Baker, R., Litman, F., Kaempf, J., Burch, K., Schwarz, E., Sun, S. Y., Payne, N. R. 2003; 111 (4)

  Abstract

  Despite increased knowledge and improving technology, chronic lung disease (CLD) rates in extremely low birth weight infants have remained constant for 20 years. One reason for this is an ineffective translation of research-proven improvements into practice. The Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) was created to provide participating nurseries the tools necessary to effect change. The objective of this study was to develop and implement a process that uses quality improvement techniques to collaboratively improve CLD rates.Nine member hospitals of the NIC/Q 2000 collaborative formed a focus group aiming to decrease CLD rates. The focus group established goals and outcome measures, created a list of potentially better practices (PBPs) based on available literature, benchmarked and performed site visits, encouraged individual site implementation of PBPs, developed a database, and measured outcomes.The goal "decrease CLD rates in extremely low birth weight infants" was established. Nine PBPs were identified, and 57 PBPs were implemented by the 9 participating sites. Twelve site visits were conducted, and a 435-patient database of infants with a mean birth weight of 789 g was established.Collaborative use of quality improvement techniques resulted in creation of a logical, efficient, and effective process to improve CLD rates. Group creation of PBPs, based on literature review and reinforced with site visits, internal data analysis, and improved individual site outcomes, resulted in accelerated and effective change, unlikely to occur if attempted outside of the collaborative.

  View details for Web of Science ID 000181960900005

  View details for PubMedID 12671162

• Implementing potentially better practices to reduce lung injury in neonates PEDIATRICS Burch, K., Rhine, W., Baker, R., Litman, F., Kaempf, J. W., Schwarz, E., Sun, S. Y., Payne, N. R., Sharek, P. J. 2003; 111 (4)

  Abstract

  Adherence to basic quality improvement principles enhances the implementation of potentially better practices (PBPs) and requires extensive planning and education. Even after PBPs have been identified and acknowledged as desirable, effective implementation of these practices does not occur easily. The objective of this study was to identify and assess implementation strategies that facilitate quality improvements in the respiratory care of extremely low birth weight infants.The 9 members of the Neonatal Intensive Care Quality Improvement Collaborative Year 2000 Reducing Lung Injury focus group identified 9 PBPs in a evidence-based manner to decrease chronic lung disease in extremely low birth weight newborns. Each site implemented several or all PBPs based on a site-specific selection process. Each site was asked to submit 1 or more examples of experiences that highlighted effective implementation strategies. This article reports these examples and emphasizes the principles on which they are based.The 9 participating institutions implemented a total of 57 PBPs (range: 1-9; median: 5). Including previous implementation, the 9 participating institutions implemented a total of 70 of a possible 81 PBPs before or during the study period (range: 5-9; median: 8). We report 7 approaches that facilitated PBP implementation: information availability, feedback, perseverance, collaboration, imitation, recognition of implementation complexity, and tracking of process indicators.Quality improvement efforts are enhanced by identifying and then implementing PBPs. In our experience, implementation of these PBPs can be difficult. Implementation strategies, such as those identified in this article, can improve the chances that quality improvement efforts will be effective.

  View details for Web of Science ID 000181960900006

  View details for PubMedID 12671163

• Agreement among measures of asthma status: A prospective study of low-income children with moderate to severe asthma PEDIATRICS Sharek, P. J., Mayer, M. L., Loewy, L., Robinson, T. N., Shames, R. S., Umetsu, D. T., Bergman, D. A. 2002; 110 (4): 797-804

  Abstract

  Because no validated "gold standard" for measuring asthma outcomes exists, asthma interventions are often evaluated using a large number of disease status measures. Some of these measures may be redundant, whereas others may be complementary. Use of multiple outcomes may lead to ambiguous results, increased type I error rates, and be an inefficient use of resources including caregiver and patient/participant time and effort. Understanding the relationship between these measures may facilitate more parsimonious and valid evaluation strategies without loss of information.To assess the relationships between multiple measures of asthma disease status over time.We used data from a randomized, controlled trial of a comprehensive disease management program involving 119 disadvantaged inner-city children aged 5 to 12 years with moderate to severe asthma. Spearman correlations were calculated between the following asthma disease status measures: parent-reported disease symptoms, parent-reported health care utilization, functional health status using the American Academy of Pediatrics' validated Child Health Survey for Asthma (CHSA), diary data (symptom scores, night wakings, and bronchodilator use), and pulmonary function tests at baseline, 32 weeks, 52 weeks, and changes from baseline to 52 weeks.Ninety-four (79%) of randomized patients participated at baseline and 52 weeks. Completion rates for outcome measures ranged from 79% (CHSA, spirometry data) to 64% (diary data). At baseline, asthma symptoms, health care utilization, and individual domains from the CHSA were significantly correlated (r = 0.21-0.53). These correlations were stable over the 52-week follow-up. Forced expiratory volume in 1 second and diary data did not correlate to any other measures at baseline, and these measures correlated only inconsistently with other measures at 32 weeks and 52 weeks. Baseline to 52-week changes in asthma symptoms, utilization, and the CHSA domains were significantly correlated (0.22-0.56), as were baseline to 52-week changes in symptom days, night wakings, and the CHSA domains (r = 0.24-0.64). Baseline to 52-week changes in forced expiratory volume in 1 second and diary data did not correlate with other measures.These results suggest that asthma status and change in asthma status over time after introduction of a disease management intervention are best characterized by parent-reported symptoms, parent-reported utilization, and functional health status measures. Asthma diaries and pulmonary function tests did not seem to provide additional benefit, although they may play an important role in individual patient management. Our findings suggest a parsimonious evaluation strategy would include collection of key data elements regarding symptoms, utilization, and functional health status only, without loss of vital response information.

  View details for Web of Science ID 000178330200033

  View details for PubMedID 12359798

• Effect of an evidence-based hand washing policy on hand washing rates and false-positive coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a level III NICU. Journal of perinatology Sharek, P. J., Benitz, W. E., Abel, N. J., Freeburn, M. J., Mayer, M. L., Bergman, D. A. 2002; 22 (2): 137-143

  Abstract

  To determine the effect of implementing an evidence-based hand washing policy on between-patient hand washing compliance and on blood and cerebrospinal fluid (CSF) culture rates in a level III neonatal intensive care unit (NICU).An evidence-based hand washing policy, supported by an intensive education program, was introduced in a regional NICU. A total of 2009 preintervention neonates (16,168 patient days) over 17 months were compared to 676 postintervention neonates (5779 patient days) over 6 months. Hand washing compliance and rates of blood and CSF cultures yielding coagulase negative staphylococci (CONS) were compared before and after intervention.Compliance with appropriate between-patient hand washing improved (from 47.4% to 85.4%, p=0.001) after the hand washing policy was introduced. The rate of cultures positive for CONS declined from 6.1+/-2.3 to 3.2+/-1.6 per 1000 patient days (p=0.005). Most of this reduction was attributable to a reduction in false-positive cultures, from 4.2+/-2.4 to 1.9+/-1.8 per 1000 patient days (p=0.042), but there was a trend toward decreased true-positive cultures (from 2.1+/-1.2 to 1.2+/-1.0 per 1000 patient days, p=0.074) as well. Potential confounders and demographics factors were similar between the control and intervention subjects.Implementation of an evidence-based hand washing policy resulted in a significant increase in hand washing compliance and a significant decrease in false-positive coagulase negative staphylococcal blood and CSF culture rates. Exploratory data analysis revealed a possible effect on true-positive coagulase negative staphylococcal blood and CSF culture rates, but these results need to be confirmed in future studies.

  View details for PubMedID 11896519

• The effect of inhaled steroids on the linear growth of children with asthma: A meta-analysis PEDIATRICS Sharek, P. J., Bergman, D. A. 2000; 106 (1)

  Abstract

  To determine whether inhaled steroid therapy causes delayed linear growth in children with asthma.Medline (1966-1998), Embase (1980-1998), and Cinahl (1982-1998) databases and bibliographies of included studies were searched for randomized, controlled trials of inhaled steroid therapy in children with asthma that evaluated linear growth.Studies were included if they met the following criteria: subjects 0 to 18 years of age with the clinical diagnosis of asthma; subjects randomized to inhaled beclomethasone, budesonide, flunisolide, fluticasone, or triamcinolone versus a nonsteroidal inhaled control for a minimum of 3 months; single- or double-blind; and outcome convertible to linear growth velocity. English- and non-English-language trials were included.Data were extracted using a priori guidelines. Methodologic quality was assessed independently by both authors. Outcome was extracted as linear growth velocity.Included trials were subgrouped by inhaled steroid. The beclomethasone subgroup, with 4 studies and 450 subjects, showed a decrease in linear growth velocity of 1.51 cm/year (95% confidence interval: 1.15,1.87). The fluticasone subgroup, with 1 study and 183 subjects, showed a decrease in linear growth velocity of.43 cm/year (95% confidence interval:.01,.85). Sensitivity analysis in the beclomethasone subgroup, which evaluated study quality, mode of medication delivery, control medication, and statistical model, showed similar results.This meta-analysis suggests that moderate doses of beclomethasone and fluticasone in children with mild to moderate asthma cause a decrease in linear growth velocity of 1.51 cm/year and.43 cm/year, respectively. The effects of inhaled steroids when given for >54 weeks, or on final adult height, remain unknown.

  View details for Web of Science ID 000087990400013

  View details for PubMedID 10878177

• Beclomethasone for asthma in children: effects on linear growth. Cochrane database of systematic reviews Sharek, P. J., Bergman, D. A. 2000: CD001282-?

  Abstract

  Inhaled steroids play a central role in the management of childhood asthma. There is concern about their side effects, especially on growth. However asthma may also cause growth retardation. Growth rates are not stable, so randomised controlled parallel group studies are needed to assess the impact of inhaled steroids on growth. This review is confine to one inhaled steroid, beclomethasone, that is known to have significant levels of systemic absorption.To determine whether inhaled beclomethasone cause significant delay in the linear growth of children with asthma.The Cochrane Airways Group asthma register was searched. Bibliographies from included studies, and known reviews were searched for additional citations. Personal contact with colleagues and researchers working in the field of asthma were made to identify potentially relevant trials.Randomized, controlled trials comparing the effects of beclamethasone to non-steroidal medication (placebo or non-steroidal therapy) on the linear growth of children with asthma.Data related to the clinical outcome "change in growth" were extracted by two reviewers working independentlyOne hundred and fifty-nine citations were identified by the search strategy and bibliography review. Three studies met the inclusion criteria. All used beclomethasone 200 mcg twice daily delivered by dry powder Diskhaler to treat children with mild-moderate asthma. Study duration was 7-12 months. In all three studies, a significant decrease in linear growth occurred in children treated with beclomethasone compared to those receiving placebo or non-steroidal asthma therapy. The average decrease, calculated through meta-analysis, was -1.54 cm per year (95% CI -1.15, -1.94).In children with mild-moderate asthma, beclomethasone 200 mcg twice daily caused a decrease in linear growth of -1.54 cm per year. These studies lasted a maximum of 54 weeks, so it remains unclear whether the decrease in growth is sustained or whether it reverses with 'catch up' after therapy is discontinued. We are unable to comment on growth effects of other inhaled steroids that have potentially less systemic effects. If inhaled steroids are required to control a child's asthma, we recommend using the minimum dose that effectively controls the child's asthma and closely following growth.

  View details for PubMedID 10796632

• THE EFFECT OF HOME OR NOVEL ENVIRONMENT ON THE FACILITATION OF PASSIVE-AVOIDANCE BY POST-TRAINING ETHANOL BEHAVIORAL AND NEURAL BIOLOGY COLBERN, D. L., Sharek, P., ZIMMERMANN, E. G. 1986; 46 (1): 1-12

  Abstract

  Passive avoidance behavior of mice is improved when mice are injected with ethanol immediately after footshock training. Further study has shown that avoidance can be affected by ethanol injections given within 1 h, but not at 90 or 180 min, after training. The present study was conducted to investigate the possibility that events which occur in the homecage during this sensitive period may influence the effect of ethanol on subsequent avoidance. Male Swiss-Webster mice were housed either singly in a novel environment for 90 min or returned to their (group) homecage following one-trial, step-through, passive avoidance training (0.1 mA footshock) and intraperitoneal injection of 3.0 g/kg ethanol (15% v/v) or saline. As in previous studies, when ethanol-treated mice were returned to their homecage, avoidance was significantly increased at 24 h compared to the behavior of saline-treated mice. However, when mice were isolated in the novel environment for 90 min immediately following treatment, the memory facilitating effects of ethanol were not observed. The avoidance behavior of mice injected with saline was the same regardless of their post-training environment. Also, the number of mice (6 or 10) housed per homecage did not significantly influence the effects of ethanol or post-training environment on avoidance. These findings indicate that environmental factors may interact with the effects of ethanol to modify avoidance behavior. The possible influence of variables such as aggression, thermoregulation, and behavioral arousal on the effects of ethanol in this paradigm are discussed.

  View details for Web of Science ID A1986C750000001

  View details for PubMedID 3729894