Implementation of a "threat and error" model in complex neonatal cardiac surgery patients to identify quality...

Area of Science:

• Pediatric Cardiac Surgery
• Quality Improvement Science
• Patient Safety

Background:

• Neonates undergoing congenital heart disease surgery face significant risks and adverse events.
• Traditional quality improvement methods may miss systematic issues not directly tied to errors but contributing to poor outcomes.
• A multidisciplinary "flight path" approach can identify modifiable threats and errors in surgical patient care.

Purpose of the Study:

• To evaluate the effectiveness of a neonatal "flight path" initiative in identifying quality improvement opportunities for congenital heart disease surgical patients.
• To assess the feasibility of implementing a multidisciplinary review process for surgical patient care pathways.
• To determine if the "flight path" process can generate actionable items for enhancing patient safety and outcomes.

Main Methods:

• A retrospective review of a neonatal "flight path" initiative was conducted over a 1-year period.
• A multidisciplinary patient care team meeting occurred within 72 hours of cardiac surgery to generate a "flight path" graphic.
• Threats, errors, unintended consequences were identified, and action items were generated and logged for quarterly analysis.

Main Results:

• Thirty-one patients were reviewed using the "flight path" process.
• Seven patients (22.5%) had an error-free "flight path."
• Eleven action items were generated from identified errors and threats, with nine completed.

Conclusions:

• "Flight path" reviews are a resource-efficient method for identifying quality improvement opportunities in congenital cardiac surgery.
• The "flight path" process facilitates the detection of potential issues in patient care pathways.
• Regular multidisciplinary meetings within the "flight path" framework enhance inter-professional teamwork and communication.