The Case of the 10 Pound Giant: A Near Miss Root Cause Analysis

Objectives: Through an Interprofessional Root Cause Analysis of this Near Miss event, we aimed to: 1.Identify issues contributing to the incorrect dosing of acyclovir 2.Understand relevant institutional policies and compare this to usual practice 3.Propose possible solutionshttp://jdc.jefferson.edu/patientsafetyposters/1034/thumbnail.jp

Evaluating salvage electroconvulsive therapy for the treatment of prolonged super refractory status epilepticus: A case series

•Electroconvulsive therapy (ECT) may treat super-refractory status epilepticus (SRSE).•Evaluation of ECT in SRSE lacks unbiased, blinded review of EEG data.•ECT was associated with resolution of SRSE and improvement in EEG.•ECT was associated with decreased need for anesthetic infusion.•ECT was not associated with adverse events. Clinicians have treated super refractory status epilepticus (SRSE) with electroconvulsive therapy (ECT); however, data supporting the practice are scant and lack rigorous evaluation of continuous electroencephalogram (cEEG) changes related to therapy. This study aims to describe a series of patients with SRSE treated at our institution with ECT and characterize cEEG changes using a blinded review process. We performed a single-center retrospective study of consecutive patients admitted for SRSE and treated with ECT from January 2014 to December 2022. Our primary outcome was the resolution of SRSE. Secondary outcomes included changes in ictal-interictal EEG patterns, anesthetic burden, treatment-associated adverse events, and changes in clinical examination. cEEG was reviewed pre- and post-ECT by blinded epileptologists. Ten patients underwent treatment with ECT across 11 admissions (8 female, median age 57 years). At the time of ECT initiation, nine patients had ongoing SRSE while two had highly ictal patterns and persistent encephalopathy following anesthetic wean, consistent with late-stage SRSE. Super-refractory status epilepticus resolution occurred with a median time to cessation of 4 days (interquartile range [IQR]: 3–9 days) following ECT initiation. Background continuity improved in five patients and periodic discharge frequency decreased in six. There was a decrease in anesthetic use following the completion of ECT and an improvement in neurological exams. There were no associated adverse events. In our cohort, ECT was associated with improvement of ictal-interictal patterns on EEG, and resolution of SRSE, and was not associated with serious adverse events. Further controlled studies are needed

Improving Resident Confidence and Efficiency During Stroke Alerts Through Simulation Training

Objectives Teach incoming neurology residents how to respond efficiently and appropriately to stroke alerts Improve the confidence level of residents during stroke alertshttps://jdc.jefferson.edu/patientsafetyposters/1084/thumbnail.jp

Adaptation of a Standardized Handoff System for a Radiology Residency Program

Background/Objectives: The Joint Commission has linked communication failure as a root cause for a majority of sentinel events. The “I-PASS” system is a hand-off mnemonic that has been shown to decrease medical errors, prevent adverse events, and improve communication. Multiple Jefferson residency programs have adopted I-PASS training over the last year to standardize sign-outs between treatment teams and departments. Radiology residents also participate in hand-offs with other departments, especially in cases of adverse patient reactions that occur within radiology (ie: allergic reaction, seizure, contrast extravasation). In addition, radiology residents also participate in hand offs between daytime and overnight teams, including sign out of pertinent protocols, studies, and clinician communications. The aim of this study was to assess the adaptability of I-PASS training to the needs of a diagnostic radiology residency program.https://jdc.jefferson.edu/patientsafetyposters/1098/thumbnail.jp

Utilizing feedback as a mechanism to improve resident event reporting rates

Objectives Provide feedback to 100% of residents entering a report between December 2017 and March 2018 Evaluate the degree to which residents value the feedback we were able to provide Assess a pilot process for sustainability on a larger scalehttps://jdc.jefferson.edu/patientsafetyposters/1099/thumbnail.jp

Improving Medical and Endovascular Management for Acute Ischemic Stroke Through Multidisciplinary Education and Simulation

Primary goals: Reduce door to treatment times (both DTN and DTP) to meet and exceed existing guidelines metrics. Educate residents about acute stroke management, including national guidelines and new institutional protocols to improve efficiency during stroke alerts.https://jdc.jefferson.edu/patientsafetyposters/1097/thumbnail.jp

Improving Bedside Procedural Safety through Optimizing Timeout Documentation and a Pre-procedure Checklist

Aim GOAL: Improve the safety of patients undergoing bedside procedures while maintaining the full spectrum of graduated autonomy in procedure training for residents. SMART Aim: Increase the rate of timeouts documented for bedside procedures from 29% to 50% by June 2018.https://jdc.jefferson.edu/medposters/1014/thumbnail.jp

Implementation of Attending-Supervised IPASS Handoff in the Neuro-ICU

Background Duty hour restrictions, cross coverage, and the growing number of mid-level practitioners has led to an increased number of handoffs across medical specialties These handoffs are well-known points of communication breakdown which can lead to patient safety issues Factors contributing to an effective handoff include standardization of communication, appropriate training and supervision, ample time, a quiet environment, and a supportive culture We hypothesize that attending supervision of handoffs is feasible and can improve practitioner perception of transitions of carehttps://jdc.jefferson.edu/patientsafetyposters/1077/thumbnail.jp