Development and Preliminary Testing of the Coordination Process Error Reporting Tool (CPERT), a Prospective Clinical Surveillance Mechanism for Teamwork Errors in the Pediatric Cardiac ICU

Abstract

Background: Patient safety reporting systems (PSRSs) may not detect teamwork or coordination process errors that affect all dimensions of quality defined by the Institute of Medicine. This study aimed to develop and observe the performance of a novel tool, the Coordination Process Error Reporting Tool (CPERT), as a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Methods: Providers and parents used the qualitative nominal group technique to identify coordination process error examples. Using categories developed from these discussions, the CPERT was designed and observed to assess agreement among providers and with the PSRS. For each patient at the end of each observed shift, the nurse, frontline clinician, and attending physician were invited to complete the CPERT online. Responses among providers were compared to assess interobserver agreement. Patients with errors identified by the CPERT were matched 1:1 with patients without CPERT errors within the same shift. The PSRS and medical record were reviewed to judge whether a coordination process error occurred and whether patients with CPERT errors differed from controls.

Results: Eight categories of errors were identified and incorporated into the CPERT. During 10 shifts (218 patients), the CPERT completion rate was 74%. Fifty-one patient shifts had errors identified by the CPERT (23%); these patients did not differ significantly from those without CPERT- reported errors. Only 5 CPERT-reported errors (10%) were identified by two or more providers. Of the 51 CPERT- reported errors, 43 (84%) were not documented in the PSRS.

Conclusion: The CPERT detects coordination process errors not identified through PSRS, making it or similar tools potentially useful for improvement efforts.

Figure 1.

Patient flow diagram