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Reducing the Morbidity Associated With Incorrect Pediatric Tracheostomy Tube Placement: A Quality Improvement

Alisha R Pershad1,2, Maria Peña2, Habib Zalzal2

  • 1School of Medicine and Health Sciences, George Washington University, Washington, USA.

Cureus
|May 5, 2025
PubMed

Insights

A quality improvement project reduced tracheostomy documentation errors by enhancing electronic medical record (EMR) access to patient information. This initiative significantly improved patient safety and reduced adverse events in pediatric tracheostomy care.

Area of Science:

  • Pediatric Healthcare Quality Improvement
  • Medical Informatics
  • Patient Safety Research

Background:

  • Pediatric patients discharged with tracheostomy tubes (TT) face significant morbidity and mortality risks.
  • Accurate documentation is crucial for managing TT patients effectively.
  • Existing electronic medical record (EMR) systems present challenges in accessing timely TT information.

Purpose of the Study:

  • To reduce tracheostomy documentation errors by at least 50% in pediatric patients.
  • To sustain this reduction for a minimum of six months.
  • To improve patient safety and reduce adverse outcomes associated with tracheostomy care.

Main Methods:

  • Utilized the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles.
  • Developed a key driver diagram (KDD) to identify EMR information access challenges.
  • Implemented an EMR alert system for patients with TT diagnosis codes to provide immediate access to critical information.

Main Results:

  • Reduced the average documentation error rate from 1 in 40 patients to 1 in 137 patients.
  • Observed only one safety event in the 180-day pilot period after alert implementation.
  • Demonstrated a significant increase in the interval between tracheostomy documentation errors.

Conclusions:

  • Enhanced access to accurate TT information in the EMR leads to improved patient safety and reduced adverse events.
  • Routine tracking of events and multi-interventional approaches can further optimize care.
  • Recommends implementing this straightforward EMR alert system to minimize catastrophic outcomes in pediatric tracheostomy care.
Abstract

Keywords:
pediatric airwaypediatric otolaryngologyquality improvementtracheostomy caretracheostomy tube

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