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Implementation of a “threat and error” model in complex neonatal cardiac surgery patients to identify quality improvement opportunities

Published online by Cambridge University Press:  01 June 2020

Deanna R. Todd Tzanetos Open the ORCID record for Deanna R. Todd Tzanetos [Opens in a new window] ,
Vicki Montgomery ,
William Harrington  and
Aaron Calhoun
Deanna R. Todd Tzanetos*
Affiliation:
Department of Paediatrics, Division of Critical Care, University of Louisville School of Medicine, Louisville, KY, USA
Vicki Montgomery
Affiliation:
Department of Paediatrics, Division of Critical Care, University of Louisville School of Medicine, Louisville, KY, USA
William Harrington
Affiliation:
Speed School of Engineering, University of Louisville, Louisville, KY, USA
Aaron Calhoun
Affiliation:
Department of Paediatrics, Division of Critical Care, University of Louisville School of Medicine, Louisville, KY, USA
*
Author for correspondence: Deanna Todd Tzanetos, MD, MSCI, 571 S. Floyd St. Suite 332 Louisville, KY40202, USA. Tel: +1 502 852 8633; Fax: +1 502 852 3998; E-mail: [email protected]
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Abstract

Introduction:

Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary “flight path” process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement.

Methods:

A retrospective review of our neonatal “flight path” initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A “flight path” is generated, graphically illustrating the patient’s hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient’s flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends.

Results:

Thirty one patients underwent flight path review over a 1-year period; 22.5% (N = 7) of patients had an error-free “flight.” Eleven action items were generated – four from identified errors and seven from identified threats. Nine action items were completed.

Conclusions:

Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.

Keywords

Congenital cardiac surgeryquality improvementpaediatrics
Type
Original Article
Information
Cardiology in the Young , Volume 30 , Issue 6 , June 2020 , pp. 860 - 865
Copyright
© The Author(s), 2020. Published by Cambridge University Press

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