Use of Systems Factors Approach to 100% Mortality Review in Pediatric Setting

Problem: In 2019, an institution goal of a 100% review of all pediatric mortalities was established to identify and provide insight to areas of improvement. A systems factors approach was implemented to better classify and trend gaps and establish quality improvement initiatives.

Measurement: A retrospective query of patients reviewed from December 2020 to January 2022 was performed. A total of 101 cases were reviewed and thematic analysis of systems factors was completed. cases were stored in a secure database that tracks cases reviewed along with systems factors and action items identified.

Analysis: Of the 101 cases reviewed, 76% were ICU cases, 10% inpatient-med-surg, 10% were Peds Emergency Department (PED), and 3% were outside deaths. Cardiology 33%, Neonatal 22%, Pulmonary 14% and Traumatic 9% causes of deaths had the highest volumes.

Implementation: 10 Systems Factors were used in the framework. 46 cases had no systems factors identified. Of the 55 remaining cases, 60% were attributed to Policies/Guidelines/Education, 31% information management, 29% Care Coordination, and 13% Human Resources. 47% cases had multiple systems factors identified during the review.

Results/Discussion: Thorough review of the identified systems factors could highlight potential areas of improvement where targeted action items and interventions can be implemented to improve the quality of care in pediatric hospitals.

Quality and Safety Program Coordinator
Quality and Safety Program Coordinator - Johns Hopkins Children’s Center

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Quality and Safety Program Coordinator
Quality and Safety Program Coordinator - Johns Hopkins Children's Center

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