GME Patient Safety Quality and Innovation Symposium

Background:

Mifepristone is used for both medication abortion and medical management of early pregnancy loss (EPL). In 2023 the FDA REMS for mifepristone was modified, allowing pharmacies to become certified to dispense mifepristone. This modification facilitated medication abortions via additional providers, and telehealth, which studies have shown is equally safe and effective compared to in-person medication abortion care. Despite the evidence supporting medication abortion without an in-person clinic visit and the ability of pharmacies to dispense these medications, this is not yet a routine part of abortion care. It is unknown how many pharmacies are certified to order, stock, and dispense mifepristone.

Description:

This project aims to understand the number of San Diego pharmacies that are able to dispense mifepristone. In addition, among pharmacies not dispensing, we assessed interest in being able to dispense mifepristone.

Study team members called all retail pharmacies in San Diego County. The team member asked standardized questions to understand if the contacted pharmacy could dispense mifepristone (Figure 1). Further, for independent retail pharmacies that are not certified, the study team member asked if they were interested in becoming certified to dispense mifepristone. Once we found pharmacies currently dispensing mifepristone, we requested approval to add them to the Medication Abortion Pharmacies website directory (https://medicationabortionpharmacies.com), where clinicians and patients can identify participating pharmacies (Figure 2). We also identified independent retail pharmacies that are not currently certified and encouraged the use of a grant through the Pharmacists CARE initiative (https://birthcontrolpharmacist.com/advocacy-initiatives/care/) to increase the number of pharmacies dispensing mifepristone in San Diego County.

Lessons learned or expected outcomes:

Of the 176 licensed pharmacies in San Diego County, 16 (9.1%) pharmacies were excluded from the sample size given they were found to be closed door pharmacies that would not be expected to dispense mifepristone. Of the 160 eligible retail pharmacies, we were able to reach a staff member at 143 (89.4%) pharmacies and found that 29 (20.3%) are certified, 4 (2.8%) were unsure if they are certified, 1 (0.7%) was in the process of becoming certified, and 109 (76.2%) are not certified and thus unable to dispense the medication. Among the 29 certified pharmacies, 26 stock mifepristone in their pharmacy, and 3 would need to order the medication. Additionally, 17 of the 29 (58.6%) certified pharmacies gave permission to have their pharmacy added to the Medication Abortion Pharmacies website directory. Of the 110 pharmacies not certified, 34 qualified as independent retail pharmacies. Of these 34 pharmacies, 15 (44.1%) were interested in becoming certified.

Recommendations/next steps:

Independent pharmacies interested in becoming mifepristone providers will be contacted again in 3-6 months to determine if they are certified to dispense mifepristone and will be added to the Medication Abortion Pharmacies website. Ultimately the goal is to decrease barriers for clinicians prescribing mifepristone, improve patient access to medication abortion, and increase flexibility for patients undergoing a medication abortion or medical management of EPL.

Needs and Objectives  

Medical residents face significant emotional challenges during demanding rotations, such as the two-week ward rotation at UCSD Jacobs Medical Center. During this rotation, residents care for patients with complex medical conditions and frequently lead goals of care discussions. In our pre-survey, 56% of residents agreed or strongly agreed that they “feel personally affected when providing care to terminally ill patients.” 56% also disagreed or strongly disagreed with the statement, “I have time to process emotionally challenging patient encounters during clinical rotations.” Therefore, we developed and implemented the Resiliency Roundtable Process Group to provide a safe and structured environment to debrief and process emotionally distressing events and to equip residents with practical tools for engaging in self-care.    

Setting and Participants 

The process group is held every other Tuesday at 1 pm, occurring half-way through each two-week rotation. Groups meet outside on a private patio or in a conference room at UCSD Jacobs Medical Center. Participants include the four PGY2-PGY3 medical residents who are currently on the rotation and one facilitator—an internal medicine attending or palliative care fellow. 

Description 

Each 45-minute Resiliency Roundtable Process Group begins with a 5 to 10-minute mindfulness or meditation exercise led by the facilitator. The remainder of the session is dedicated to open discussions guided by patient care events. These sessions provide a confidential space for residents to debrief emotionally challenging events, share coping strategies with their peers, and engage in self-care practices. 

Evaluation 

Among the 21 residents who participated in at least one process group and completed the post-survey, 81% agreed or strongly agreed that the unstructured time for group discussion helped them better reflect on and cope with difficult patient encounters. 62% agreed that debrief groups gave them the time and space to process emotionally challenging patient encounters. 

Lessons Learned 

Though residents initially requested that the groups be held during regular work hours for maximum impact and attendance, resident participation was sometimes interrupted by urgent patient care needs. Facilitator recruitment was another challenge and could limit further expansion of this or similar programs. Future opportunities include extending process groups to other rotations and practice settings, securing pager-protected time, and measuring the impact of these process groups on resident and facilitator satisfaction, burnout rates, and patient care outcomes. 

Background: Hematopoietic stem cell transplantation (HSCT) survivors are at risk for developing late complications secondary to peri-transplantation exposures. National guidelines recommend screening for late effects of HSCT, including endocrine disorders. At our institution, we observed that adherence to guidelines was suboptimal. Among pediatric allogeneic HSCT recipients with hematologic malignancy or severe aplastic anemia (SAA) diagnosis, only 1/16 patients (6%) received all the recommended screening evaluations/tests at 12 and 24 month follow-up visits between January and September, 2023.

Methods: Global Aim: Improve long-term endocrine health in HSCT survivors.

SMART Aim: From July 1, 2024 to May 31, 2025, the percentage of allogeneic HSCT recipients with hematologic malignancy or SAA diagnosis at Rady Children’s Hospital-San Diego, who receive all the recommended endocrine screening evaluations/tests at 12 and 24 months after transplant, will increase from 6% to 60%. 

Our interprofessional team (oncology, nursing, IT) used Quality Improvement (QI) tools (process mapping, fishbone and key-driver diagrams) to inform interventions: Provider education sessions, tip sheets, Epic order panel, and Epic smart-phrase with list of test results to be included in clinic notes.

Process measures include: 

Percent of clinic visit notes at 12 and 24 months post- HSCT for hematologic malignancy or SAA in which new Epic smart phrase was utilized. Percent of clinic visits at 12 and 24 months post- HSCT for hematologic malignancy or SAA in which new Epic order panel was utilized.

Balancing measures include: Provider satisfaction with new process, measured via survey.

Results: Within the first 3 months from project roll out (PDSA1) the percentage of HSCT recipients who received all the recommended endocrine screening evaluations/tests at 12 and 24 months post-HSCT increased to 33%. Only 3/9 evaluated patients had Tanner stage documented. Adherence to all other screening tests was 100% (increased from 25% at baseline). The Epic smart-phrase was utilized in 9/9 (100%) of clinic notes. The Epic order panel was utilized in 5/9 (56%) of evaluated clinic encounters. The PDSA2 is currently ongoing with 3 patients evaluated so far. All had 100% of screening evaluations/tests, including Tanner stage, performed.

Conclusions: After PDSA1, we increased adherence to endocrine screening evaluations/tests for HSCT survivors. Interprofessional collaboration, provider engagement and use of newly developed Epic tools facilitated improvement. However, we have not yet reached our goal.  During PDSA2 we are focusing our strategy on improving adherence to Tanner stage documentation, identified as the main contributor to not achieving our SMART Aim. Additional interventions for PDSA2 included additional provider education sessions and updated tip sheets to emphasize inclusion of tanner staging.

Pediatric post-tonsillectomy hemorrhage (PTH) affects  up to 6.7% of patients. Nebulized tranexamic acid (nTXA) is low in cost, safe, achieves hemostasis, and decreases the return to the OR (ROR). Only 14% of patients who presented to the ED at a large pediatric emergency department received nTXA.

Background: Dermatologists often have limited exposure to the management of oral mucositis, despite its frequent occurrence in patients with autoimmune blistering conditions, severe cutaneous drug reactions, congenital blistering disorders, and other dermatologic diseases. This gap in familiarity presents a challenge in providing optimal care for affected patients. Furthermore, oral mucositis can significantly impact quality of life, nutrition, and overall health, necessitating a standardized and evidence-based approach to treatment. Given the overlap between dermatologic conditions and oral mucosal involvement, equipping dermatologists with structured management tools is essential. To address this, we conducted a comprehensive literature review and developed clinical decision-support tools in the form of smartphrases (dotphrases) to standardize treatment approaches.

Methods: A literature review was performed on updated oral mucositis management guidelines, focusing on studies involving cancer patients undergoing chemoradiation therapy, as this population has the most robust evidence base. Using this information, we developed comprehensive dotphrases detailing treatment options based on their mechanism of action, patient selection criteria, dosing recommendations, adverse effects, and supporting literature references. These dotphrases underwent review by the UCSD Palliative Care Department and UCSD Nutritionists, with their feedback incorporated since January 2025 to enhance clinical applicability. We also distributed pre- and post-intervention survey to evaluate how the confidence of a single institution dermatology department was affected by implementation of these updated guidelines.

Results: The finalized guidelines include structured treatment guidance for oral mucositis of any etiology, ensuring ease of use and integration into clinical workflows. Each treatment option is detailed with:

Mechanism of Action: Clarifying how each intervention mitigates mucositis.

Potential Patients: Identifying patients who may benefit from specific treatments.

Dosing: Standardized dosages as reported in clinical studies.

Adverse Effects: Known side effects to guide risk-benefit discussions.

Literature Reference: A supporting recent publication for evidence-based application.

Additionally, we developed five general-purpose dotphrases to support clinical management:

Malnutrition Screening Tool: A standardized method to identify patients at risk of

malnutrition.

Assessment and Plan for Oral Mucositis: Includes WHO scoring and a severity-based treatment algorithm.

After Visit Summary (AVS): Patient-friendly instructions based on individualized treatment plans.

Treatment Guide: A reference tool for integrating treatment-specific dotphrases into workflows.

Nutritional Recommendations: General dietary guidance for patients at high risk of malnutrition while awaiting formal nutrition consultation.

Conclusions: Our structured dotphrases provide a standardized, evidence-based approach to managing oral mucositis across various patient populations, including those under dermatologic care. By incorporating expert input from palliative care and nutrition specialists, we have ensured clinical relevance and usability. This project has already been implemented by the UCSD palliative care providers since its review and approval in February 2025. Confidence in management and counseling of oral mucositis has improved with implementation of these literature-based smartphrases. The implementation of these smartphrases will hopefully facilitate improved patient outcomes through streamlined assessment, treatment, and follow-up care. Future directions include assessing clinician adoption and patient outcomes following the implementation of these tools in clinical practice.

Background

Umbilical cord management is a critical aspect of neonatal care, impacting both immediate and long-term health outcomes for newborns. The timing of cord clamping and the methods used can significantly influence the infant's adaptation to extra-uterine life, affecting parameters such as blood volume, iron status, and respiratory transition. Current guidelines and practices vary widely, necessitating optimizing these procedures based on the latest evidence.

Description of the Project

Our setting is the University of California San Diego NICU, a 52 bed Level 3 NICU with a birthing center that delivers approximately 40 infants with gestational age < 30 weeks per year. Recently, our unit adopted an innovative approach involving trolley deliveries (Figure 2) for delayed cord clamping (DCC) of 90 seconds as part of a multicenter randomized clinical trial. This method facilitates the initiation of ventilation while the infant remains attached to the umbilical cord.

Lessons Learned/Expected Outcomes

Recent CPQCC data show that DCC > 60 seconds improved in 2024 after initiation of the trolley. It increased from annual averages of 10-15% to 36.5%. However, we seek to impact more of our < 30 weeks infant population. We are initiating a QI project with the aim to increase the duration of delayed cord clamping (DCC) to 90 seconds in preterm infants (<30 weeks gestational age) by 20% within six months, from May 2025 to October 2025. Process measures of tracking trolley use and neonatal provider involvement at DCC will allow us to follow adherence to our proposed guidelines. Balancing measures will track intubation rates and initial hypothermia on admission to the NICU in the setting of DCC. 

Recommendations/Next Steps

We are establishing a multidisciplinary team comprised of members from both the obstetrics and neonatal teams. Key drivers (Figure 1) have been identified to develop targeted interventions to enhance DCC rates. Baseline monthly data from 2022-2024 is being collected and will be analyzed on a statistical process control chart. DCC process will be further explored and discussed with our multidisciplinary team through fishbone diagrams and process mapping. We anticipate that these measures will result in us achieving our aim and primary outcome measure of increasing the duration of DCC to 90 seconds in infants < 30 weeks with a global aim of improving health outcomes for our smallest infants.

Background:

Mifepristone is used for both medication abortion and medical management of early pregnancy loss (EPL). In 2023 the FDA REMS for mifepristone was modified, allowing pharmacies to become certified to dispense mifepristone. This modification facilitated medication abortions via additional providers, and telehealth, which studies have shown is equally safe and effective compared to in-person medication abortion care. Despite the evidence supporting medication abortion without an in-person clinic visit and the ability of pharmacies to dispense these medications, this is not yet a routine part of abortion care. It is unknown how many pharmacies are certified to order, stock, and dispense mifepristone.

Description:

This project aims to understand the number of San Diego pharmacies that are able to dispense mifepristone. In addition, among pharmacies not dispensing, we assessed interest in being able to dispense mifepristone.

Study team members called all retail pharmacies in San Diego. The team member asked standardized questions to understand if the contacted pharmacy could dispense mifepristone. Further, for independent retail pharmacies that are not certified, the study team member asked if they were interested in becoming certified to dispense mifepristone. Once we found pharmacies currently dispensing mifepristone, we requested approval to add them to the Medication Abortion Pharmacies website directory (https://medicationabortionpharmacies.com), where clinicians and patients can identify participating pharmacies. We also identified independent retail pharmacies that are not currently certified and encouraged the use of a grant through the Pharmacists CARE initiative (https://birthcontrolpharmacist.com/advocacy-initiatives/care/) to increase the number of pharmacies dispensing mifepristone in San Diego.

Lessons learned or expected outcomes:

Of the 176 licensed pharmacies in San Diego County, 22 (12.5%) pharmacies were excluded from the sample size given they were found to be closed-door or specialty pharmacies that would not be expected to dispense mifepristone. Of the 154 eligible retail pharmacies, we were able to reach a staff member at 149 (96.8%) pharmacies and found that 33 (22.1%) are certified, 1 (0.7%) was in the process of becoming certified, and 115 (77.2%) are not certified and thus unable to dispense the medication. Of the 115 pharmacies not certified, 35 qualified as independent retail pharmacies. Of these 35 pharmacies, 16 (45.7%) were interested in becoming certified.

Recommendations/next steps:

Independent pharmacies interested in becoming mifepristone providers will be contacted again in 3-6 months to determine if they are certified to dispense mifepristone and will be added to the Medication Abortion Pharmacies website. Ultimately, the goal is to decrease barriers for clinicians prescribing mifepristone, improve patient access to medication abortion, and increase flexibility for patients undergoing a medication abortion or medical management of EPL.

Background: Patients with acute neurological illness requiring hospitalization have a specific set of inpatient needs that are distinct from those who are admitted for primary medical or surgical indications. Many of these needs can be addressed on initial admission with specific orders. Currently, the inpatient general neurology team uses the “acute care non-ICU admission” order set for all admissions onto the service that is an order set that is available to all UCSD services. However, this admission order set is not tailored to meet the specific needs of a patient population that is ill with an acute neurological disorder requiring hospitalization.

Description: Earlier in this academic year, an M&M conference was held by the clinical service chair, inpatient neurology faculty, and neurology residents regarding an inpatient case. A root cause analysis was conducted during this M&M that determined the “acute care non-ICU admission” order set was not optimized to fit the management of the neurologically ill patient population. This quality improvement project describes the creation of a new general neurology admission order set that include neurology-specific admission orders that are not included in the current acute care admissions order set. Some of these specific needs include: presence and frequency of neurological exam checks, physical, occupational, and speech therapy evaluations, and holding DVT prophylaxis prior to lumbar punctures.

Lessons learned and next steps: The initial order set has been used by a select number of neurology residents who are giving input on common orders to include, with focus on residents who are rotating through their night float rotation which offers more independence. We expect this new tailored order set will improve ease of admitting patients on a high-volume service as well as reduce commonly “missed” orders, such as PT evaluations and DVT prophylaxis timing in anticipation for procedures. Our next steps include neurology resident wide implementation and adjustments to the order set based on any preliminary feedback.

Introduction:

Current universal standards of care in the healthy newborn include intramuscular vitamin K (prevent vitamin K deficiency bleeding), topical erythromycin (prevent gonococcal ophthalmia neonatorum), hepatitis B vaccination (prevent hepatitis B), newborn screen (identify significant congenital diseases), hearing screen, and pulse oximeter screening for critical congenital heart disease.1-6 However, refusals for these services have been increasing.7 Other studies have identified factors that may contribute to declinations, but these studies have variable refusal patterns especially with refusal of all interventions.8-9 Most studies previously focused on vitamin K, erythromycin, and hepatitis B vaccine refusals, but none have been comprehensive to include other recommended preventative efforts.

Objectives:

Assess rates and patterns of refusal. Identify common demographic and clinical factors in families who refusal these neonatal preventative services.

Materials and Methods:

This is a quality improvement, retrospective chart review study looking at data over a span of five years (2018-2023) of singleton newborns, gestational age ≥ 37 weeks, born at two University of California San Diego Health newborn nurseries. Statistical analysis was used to assess refusal outcomes, rates of refusal, and chi square analysis was used to determine significance between various demographic and clinical factors.

Results:

17,618 charts were reviewed. Of the entire population, 11% refused at least one preventative service, 8% refused more than one, and 0.2% refused all the recommended services. Hepatitis B had the most refusals followed by erythromycin and then vitamin K. There were refusers of the newborn screen, hearing  screen, and CCHD, but less than 1% each. There were significantly higher rates of refusal of hepatitis B in families who were English speaking, had increased maternal age, delivered in birth centers, had certified nurse midwives as providers, and delivered vaginally. People who had lower social vulnerability index (SVI) had the most refusals compared to upper and middle SVI categories.

Conclusion:

For families that refuse recommended neonatal preventative services, our data has shown that there are certain patterns of refusals. There are also significant differences in certain demographic and clinical characteristics of families that refuse the hepatitis B vaccine. This has enlightened possibilities of future targeted educational interventions in hopes of increasing compliance with these recommended preventative services.

References

[1] Hand I, Noble L, Abrams SA. Vitamin K and the Newborn Infant. Pediatrics.

2022;149(3):e2021056036. doi:10.1542/peds.2021-056036

[2] US Preventive Services Task Force, Curry SJ, Krist AH, et al. Ocular Prophylaxis for

Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation

Recommendation Statement. JAMA. 2019;321(4):394-398. doi:10.1001/jama.2018.21367

[3] Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the

United States: Recommendations of the Advisory Committee on Immunization Practices.

MMWR Recomm Rep. 2018;67(1):1-31. Published 2018 Jan 12. doi:10.15585/mmwr. S,

Ojodu J. Infants with Congenital Diseases Identified through Newborn Screening-United

States, 2018-2020. Int J Neorr6701a

[4] Gaviglio A, McKasson S, Singh natal Screen. 2023;9(2):23. Published 2023 Apr 13.

doi:10.3390/ijns9020023

[5] van Straaten HL. Automated auditory brainstem response in neonatal hearing

screening. Acta Paediatr Suppl. 1999;88(432):76-79. doi:10.1111/j.1651-

2227.1999.tb01165.x

6] Martin GR, Ewer AK, Gaviglio A, et al. Updated Strategies for Pulse Oximetry Screening

for Critical Congenital Heart Disease. Pediatrics. 2020;146(1):e20191650.

doi:10.1542/peds.2019-1650

[7] Marcewicz LH, Clayton J, Maenner M, et al. Parental Refusal of Vitamin K and Neonatal

Preventive Services: A Need for Surveillance. Matern Child Health J. 2017;21(5):1079-1084.

doi:10.1007/s10995-016-2205-8

[8] Loyal J, Taylor JA, Phillipi CA, et al. Factors Associated With Refusal of Intramuscular

Vitamin K in Normal Newborns. Pediatrics. 2018;142(2):e20173743.

doi:10.1542/peds.2017-3743

[9] Danziger P, Skoczylas M, Laventhal N. Parental Refusal of Standard-of-Care

Prophylactic Newborn Practices: In One Center's Experience, Many Refuse One but Few

Refuse All. Hosp Pediatr. 2019;9(6):429-433. doi:10.1542/hpeds.2019-002