P0125 - Establishing Effective and Sustainable Pediatric Emergency Department Adverse Event Review Process

Background and

Purpose: Preventable adverse events lead to significant patient morbidity and mortality. Multiple factors associated with acute care delivery, including chaotic environment, shift work, frequent hand offs, and interruptions, may contribute to preventable adverse events. Consistent reporting and review of adverse events and near misses may help identify and correct underlying causes. Our objective was to create a sustainable and effective adverse event review system in pediatric emergency network system. We aimed to establish a sustainable (at least 80% of sessions with 4-12 cases) and effective (at least 1 action item per session) standardized Emergency Department (ED) and Urgent Care (UC) Case Review process for by December 2019.

Methods: We established Emergency Department Case Review Committee (EDCRC), a multidisciplinary group that meets for 2 hours each month to review selected ED/UC cases. EDCRC consists of site medical directors, front line providers, nursing representatives, critical care and education liaisons, process improvement and diagnostic error experts. EDCRC reviews all ED mortalities, selected cases from hospital adverse event reporting system, selected patient complaints as well as cases referred by ED/UC and specialty teams. Figure 1 outlines EDCRC process. Interventions to increase sustainability and effectiveness included review tool implementation (standardized case review form, team notification templates), pre-screening of referred cases, fishbone tool for case analysis, action item tracking, use of case classification system. The primary outcome was percent of sustainable sessions annually (defined as 4-12 cases per session). Secondary outcome was percent effective sessions annually (defined as least one action item generated per session). Balancing measure was percentage of sessions with at least 5 team members and number of cancelled sessions.

Results: Data was collected from May 2016 to December 2019. 30 out of 44 possible EDCRC session took place during that time. Percent of sustainable sessions increased from 50% in 2016 to 91% in 2019. Percent of effective sessions increased from 25% in 2016 to 83% in 2019. No sessions were cancelled in 2019 and 100% of sessions in that year were well attended (see Table 1).

Conclusion: We implemented a sustainable, effective adverse event review process in our acute care network. Further efforts will include optimizing case referral process and medical team feedback mechanisms.