Improving Shared Situation Awareness for High-risk Therapies in Hospitalized Children

BACKGROUND

High-risk therapies (HRTs), including medications and medical devices, are an important driver of preventable harm in children's hospitals. To facilitate shared situation awareness (SA) and thus targeted harm prevention, we aimed to increase the percentage of electronic health record (EHR) alerts with the correct descriptor of an HRT from 11% to 100% on a high-acuity hospital unit over a 6-month period.

METHODS

The interdisciplinary team defined an HRT as a medication or device with a significant risk for harm that required heightened awareness. Our aim for interventions was to (1) educate staff on a new HRT algorithm; (2) develop a comprehensive table of HRTs, risks, and mitigation plans; (3) develop bedside signs for patients receiving HRTs; and (4) restructure unit huddles. Qualitative interviews with families, nurses, and medical teams were used to assess shared SA and inform the development and adaptation of interventions. The primary outcome metric was the percentage of EHR alerts for an HRT that contained a correct descriptor of the therapy for use by the care team and institutional safety leaders.

RESULTS

The percentage of EHR alerts with a correct HRT descriptor increased from an average of 11% to 96%, with special cause variation noted on a statistical process control chart. Using qualitative interview data, we identified critical awareness gaps, including establishing a shared mental model between nursing staff and the medical team as well as engagement of families at the bedside to monitor for complications.

CONCLUSIONS

Explicit, structured processes and huddles can increase HRT SA among the care team, patient, and family.

Management of intraoperative femur fractures associated with revision hip arthroplasty

Femoral fractures sustained during revision total hip arthroplasty (THA) are a serious complication. The incidence of intraoperative femur fractures in the period from 1982 to 1986 was ten in 159 (6.3%) THA revisions. The patients were treated primarily by surgical stabilization with compression plates and screws. All of the fractures healed, but of the ten, only six patients ultimately regained satisfactory THA function.

Arthroscopic management of lateral meniscal cysts

This study presents seven cases of lateral meniscal cysts treated arthroscopically. All were noted to have meniscal lesions at the time of surgery; there were five flap tears and two radial tears. Partial arthroscopic meniscectomy was performed and the contents of the cysts were manipulated into the joint in six of seven cases. One patient underwent open cyst excision in addition to partial arthroscopic meniscectomy. Followup ranged from 18 months to 4 years with an average of 28 months. There were no cyst recurrences. The pathologic basis of the meniscal cyst is controversial, but recent work suggests the etiology is infiltration of joint fluid through micro and macro tears in the meniscus. Partial meniscectomy retains valuable meniscal function while minimizing the likelihood of cyst reformation. We found arthroscopic partial meniscectomy with manipulation of the contents of the cyst into the joint to be a successful alternative to complete open meniscectomy.