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Jennifer Everhart, MD

  • Jennifer L Everhart

Work and Education

Professional Education

Chicago Medical School, North Chicago, IL, 2005

Residency

Children's Hospital of Orange County, Orange, CA, 2009

Board Certifications

Pediatrics, American Board of Pediatrics

All Publications

Families as Partners in Hospital Error and Adverse Event Surveillance. JAMA pediatrics Khan, A., Coffey, M., Litterer, K. P., Baird, J. D., Furtak, S. L., Garcia, B. M., Ashland, M. A., Calaman, S., Kuzma, N. C., O'Toole, J. K., Patel, A., Rosenbluth, G., Destino, L. A., Everhart, J. L., Good, B. P., Hepps, J. H., Dalal, A. K., Lipsitz, S. R., Yoon, C. S., Zigmont, K. R., Srivastava, R., Starmer, A. J., Sectish, T. C., Spector, N. D., West, D. C., Landrigan, C. P., Allair, B. K., Alminde, C., Alvarado-Little, W., Atsatt, M., Aylor, M. E., Bale, J. F., Balmer, D., Barton, K. T., Beck, C., Bismilla, Z., Blankenberg, R. L., Chandler, D., Choudhary, A., Christensen, E., Coghlan-McDonald, S., Cole, F. S., Corless, E., Cray, S., Da Silva, R., Dahale, D., Dreyer, B., Growdon, A. S., Gubler, L., Guiot, A., Harris, R., Haskell, H., Kocolas, I., Kruvand, E., Lane, M. M., Langrish, K., Ledford, C. J., Lewis, K., Lopreiato, J. O., Maloney, C. G., Mangan, A., Markle, P., Mendoza, F., Micalizzi, D. A., Mittal, V., Obermeyer, M., O'Donnell, K. A., Ottolini, M., Patel, S. J., Pickler, R., Rogers, J. E., Sanders, L. M., Sauder, K., Shah, S. S., Sharma, M., Simpkin, A., Subramony, A., Thompson, E. D., Trueman, L., Trujillo, T., Turmelle, M. P., Warnick, C., Welch, C., White, A. J., Wien, M. F., Winn, A. S., Wintch, S., Wolf, M., Yin, H. S., Yu, C. E. 2017

Abstract

Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; , 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.Error and AE rates.Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P=.006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

View details for DOI 10.1001/jamapediatrics.2016.4812

View details for PubMedID 28241211

Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment JOURNAL OF HOSPITAL MEDICINE Rosenbluth, G., Bale, J. F., Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Sectish, T. C., Landrigan, C. P. 2015; 10 (8): 517-524

Abstract

Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking.To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents.Pediatric hospitalist services at 9 institutions in the United States and Canada.Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices.Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended.Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

View details for DOI 10.1002/jhm.2380

View details for Web of Science ID 000358693600007

View details for PubMedID 26014471

The Creation of Standard-Setting Videos to Support Faculty Observations of Learner Performance and Entrustment Decisions Academic Medicine Calaman, S., Hepps, J., Bismilla, Z., Carraccio, C., Englander, R., Feraco, A., Landrigan, C., Lopreiato, J., Sectish, T., Starmer, A., Yu, C., Spector, N., West, D., I-PASS Study Education Executive Committee 2015; 91 (2): 204-9
Changes in medical errors after implementation of a handoff program. New England journal of medicine Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., Bismilla, Z., Coffey, M., Mahant, S., Blankenburg, R. L., Destino, L. A., Everhart, J. L., Patel, S. J., Bale, J. F., Spackman, J. B., Stevenson, A. T., Calaman, S., Cole, F. S., Balmer, D. F., Hepps, J. H., Lopreiato, J. O., Yu, C. E., Sectish, T. C., Landrigan, C. P. 2014; 371 (19): 1803-1812

Abstract

Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking.We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events.In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time.Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

View details for DOI 10.1056/NEJMsa1405556

View details for PubMedID 25372088

Placing Faculty Development Front and Center in a Multisite Educational Initiative: Lessons From the I-PASS Handoff Study ACADEMIC PEDIATRICS O'Toole, J. K., West, D. C., Starmer, A. J., Yu, C. E., Calaman, S., Rosenbluth, G., Hepps, J. H., Lopreiato, J. O., Landrigan, C. P., Sectish, T. C., Spector, N. D. 2014; 14 (3): 221-224

View details for Web of Science ID 000335368000002

View details for PubMedID 24767774

Development, implementation, and dissemination of the I-PASS handoff curriculum: A multisite educational intervention to improve patient handoffs Academic Medicine Starmer, A., O'Toole, J., Rosenbluth, G., Calaman, S., Balmer, D., West, D., Bale, J., Yu, C., Noble, E., Tse, L., Srivastava, R., Landrigan, C., Sectish, T., Spector, N., I-PASS Study Education Executive Committee 2014; 89 (6): 876-84
I-PASS Handoff Curriculum: Medical Student Workshop MedEdPORTAL O'Toole, J., Calaman, S., Everhart, J., Bismilla, Z., Good, B., Guiot, A., Johnstone, N., Nilforoshan, V., Noble, E., Rosenbluth, G., Schwartz, S., Solan, L., Tse, L., West, D., Landrigan, C., Sectish, T., Srivastava, R., Starmer, A., Spector, N. 2014
I-PASS Handoff Curriculum: Core Resident Workshop MedEdPORTAL Spector N, Starner A, Allen A, Bale J, Bismilla Z, Calaman S, Coffey M, Cole F, Destino L, Everhart J, Hepps J, Kahana M, Lopreiato J, McGregor R, O'Toole J, Patel S, Rosenbluth G, Srivastava R, Stevenson A, Tse L, Yu C, West D, Sectish T, Landrigan C 2013
I-PASS Handoff Curriculum: Computer Module MedEdPORTAL Calaman, S., Spector, N., Starmer, A., O'Toole, J., Allen, A., Tse, L., Bale, J., Bismilla, Z., Coffey, M., Cole, F., Destino, L., Everhart, J., Hepps, J., Kahana, M., McGregor, R., Patel, S., Rosenbluth, G., Srivastava, R., Stevenson, A., West, D., Sectish, T., Landrigan, C., Yu, C., Lopreiato, J. 2013
I-PASS Handoff Curriculum: Campaign Toolkit MedEdPORTAL Spector N, Rosenbluth G, Patel S, Destino L, OToole J, Everhart J, Stevenson A, Yu C, Calaman S, Allen A, Starmer A, Landrigan C, Sectish T 2013
I-PASS, a Mnemonic to Standardize Verbal Handoffs PEDIATRICS Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C. 2012; 129 (2): 201-204

View details for DOI 10.1542/peds.2011-2966

View details for Web of Science ID 000300395100040

View details for PubMedID 22232313