Leveraging Digital Infrastructure for Immediate System Change: Pediatric Workflow Implementation in the Emergency Department

Adverse events in the emergency department (ED) require a swift and thoughtful response. Often, work from event investigations and root cause analyses is difficult to disseminate and integrate into clinical workflows for lasting practice change. Digital platforms developed in academic settings have been shown to improve clinical guideline access and adherence in the ED. Building on this foundation, we evaluated whether a digital hub (E*Drive, MercedEDrive.com) could enable rapid dissemination of a pediatric safety protocol after an adverse event in a community hospital.

Following a pediatric adverse event in December 2024, ED and hospital leadership co-created a new discharge workflow for patients ≤8 years old. Using Google Slides, asynchronous stakeholder review streamlined consensus and avoided delays inherent in traditional email-based feedback. The workflow required physician evaluation prior to disposition for young patients primarily managed by advanced practice providers (APPs) to ensure an additional layer of assessment. Standardized steps included updated vital signs, review of discharge instructions, APP–physician communication, and documentation of physician involvement. The workflow was uploaded to E*Drive, allowing immediate access for all staff. Compliance was tracked monthly through chart review.

Within 6 hours of the adverse event being reported, the new workflow was live on E*Drive. Monthly compliance rates were: January 97%, February 99%, March 96%, April 99%, May 100%, June 100%, and July 100%. After three consecutive months of 100% compliance, routine auditing was concluded, with random audits scheduled. Any chart not meeting protocol criteria triggered notification of physician leadership for follow-up.

A centralized digital platform enabled rapid, cost-effective development and dissemination of a pediatric safety protocol following an adverse event. Using E*Drive alongside departmental education supported high compliance and sustained 100% adherence. While heightened staff vigilance may have contributed, E*Drive provided critical infrastructure for swift system-wide adoption. It offers a scalable model for bridging the gap between event recognition and root cause analysis, supporting immediate patient safety improvements in emergency medicine.