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

## TL;DR

This study shows how adding an alert in electronic medical records significantly reduced errors in pediatric tracheostomy tube documentation.

## Contribution

A novel quality improvement approach using electronic medical record alerts to reduce tracheostomy-related documentation errors in pediatric patients.

## Key findings

- An alert system in the EMR reduced tracheostomy documentation errors from one in every 40 patients to one in every 137 patients.
- Only one safety event occurred during an 180-day pilot period after implementing the alert.
- The intervention improved the interval between errors and is recommended for broader implementation.

## Abstract

Introduction: Despite an increase in pediatric patients being discharged with a tracheostomy tube (TT), morbidity and mortality rates remain considerable. The aim of this quality improvement (QI) project is to reduce the proportion of tracheostomy documentation errors per 1000 tracheostomy patients by 50% or more, and sustain this for six months.

Methods: Using the Model for Improvement and a Plan-Do-Study-Act (PDSA) cycle, a key driver diagram (KDD) identified challenges in accessing accurate TT information within the electronic medical record (EMR). EMR representatives created an alert for any patient with a TT diagnosis code to provide immediate access to tracheostomy information. Assessment of this intervention was conducted using descriptive statistics and QI control charts.

Results: Prior to intervention, an average of 56 different tracheostomy patients per year were evaluated, and 15 events were recorded. Upon implementation of the alert, there was one safety event in the 180-day pilot period. Since the initial PDSA cycle, there have been two TT documentation events, improving the average from one error in every 40 patients seen over a 28-month period to one error in every 137 patients seen over a 24-month period (and counting).

Conclusion: Increased access to accurate TT information in the EMR demonstrated an increased interval between events. Future work includes routinely tracking events as a new metric to follow and implementing other interventions from the KDD for a multi-interventional approach to the global aim. We recommend that organizations implement this straightforward approach to dramatically reduce untoward outcomes with catastrophic potential.