Resilient Communication Systems: A Pediatric Patient Safety Learning Lab

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PROJECT SUMMARY/ABSTRACT Estimates suggest that nearly 1 in 10 hospitalized children may experience a safety or harm event, and communication breakdown is a leading contributor to patient safety and harm events. A 2010 study estimated that inefficient clinical communication cost US hospitals an estimated $12 billion annually in wasted clinician time and increased lengths of stay. The introduction of technologies such as smartphones and secure text messaging are transforming how, when, and what acute care clinicians communicate among each other. Developing an infrastructure to proactively evaluate these systems, and build their resilience, is critical. The goal of this project is to create a novel, nurse-led Pediatric Patient Safety Learning Lab with the objective of reengineering interprofessional (e.g., nurse-physician) communication work systems for pediatric acute care settings. The Learning Lab will consist of a multidisciplinary team of clinician-researchers, human factors engineers, human-centered design experts, and operational safety experts from Children's Hospital of Philadelphia and the University of Pennsylvania. We will also engage stakeholders, including bedside clinicians and families of hospitalized children, whose experience of care may be altered by changes to how clinicians communicate. We will use a systems engineering approach (Problem Analysis, Design, Development, Implement, and Evaluate) to proactively assess the interprofessional communication work system, processes, and outcomes, to identify opportunities for improvement before safety events occur. The Specific Aims of this project are to (1) Conduct a problem analysis of the interprofessional communication work system and work processes used in the care of hospitalized children; (2) Design and develop interventions to engineer a safer, more effective, and more resilient interprofessional communication work system; (3) Implement and evaluate the interventions in the clinical environment to gauge real-world impact. Our Learning Lab will be guided by two frameworks, the Systems Engineering Initiative for Patient Safety model and the Integrated Resilience Attributes Framework. The product of this Learning Lab will be a resilient system for interprofessional communication, one that can positively adapt in the face of anticipated and unanticipated changes and maintain the safety of care provided during the estimated 2.5 million pediatric hospitalizations each year.