Childrens Hospital of Pittsburgh of UPMC | Davies Enterprise Award

2015 Davies Award winner Children's Hospital of Pittsburgh of UPMC (CHP of UPMC) was an early adopter of electronic health records yet initially struggled to improve patient outcomes and safety. Through the development of a robust data warehouse system that provided expansive reporting capability to identify gaps and trigger change management, CHP of UPMC developed innovative Health IT-enabled workflows to:

  • lower medication errors while improving on-time delivery of medication
  • virtually eliminate errors associated with breast milk labeling, ensuring that the mother gets the correct breast milk both while in the hospital and at home
  • decrease medication safety events 60% over a six year period
  • prevent over 50 pulmonary and cardiac conditions ICU admissions through preventative care delivery triggered by CDS alerts
  • cut the CLABSI rate per 1000 patients in half

Leveraging robust reporting from a state of the art data warehouse, Children’s Hospital has significantly reduced hospital-acquired infections. A variety of clinical data populates a dashboard to generate a pediatric Rothman Index, a real time with an easy-to-understand composite score that evaluates the patient’s condition. Using this scoring and alert interface that works through both the EHR and a number of mobile devices, providers trigger early preventative measures to significantly reduce ICU admissions associated with pulmonary and cardiac events by 53 since implementation.

Read Children's Hospital of Pittsburgh of UPMC Data Warehousing and Analytics Case Study

Realizing that the larger hospital space would require a new approach, Children's Hospital pharmacy developed a strategy for medication safety.  The strategy included the following areas developed to control the medication processes:

  1. Patients receive the correct medications – Implemented Positive Patient ID (PPID) to identify a patient and the patient’s orders. Prepared medications are labeled with a barcode that indicates the patient’s medication order.
  2. Patients receive medications on time – Implemented a customized medication tracking system to track pharmacy orders from order to delivery. RFID (Radio Frequency Identification) tracking to locate infusion pumps.
  3. Automation and equipment to support medication safety – Pyxis med stations, cubies, Medication carts with locked drawers, and RFID refrigerator/freezer temperature monitoring. Finally, “Talking Boxes” are used to aid clinicians and pharmacy to automate medication safety. Aeroscout’s RFID technology is used to electronically monitor the temperature of the refrigerators and freezers throughout the hospital.  This data was previously collected manually at least once a day, logged, and reviewed. CHP’s “talking boxes” are a unique tool to warn pharmacy workers and nurses of the dangers of certain medications.  Meds that look alike, sound alike, or require special considerations provide potential areas for error. 


As result of these initiatives, missing doses were reduced by 14% while medication errors were reduced by 60%.

Read Children's Hospital of Pittsburgh Medication Management and Strategy Case Study


In 2011 to 2013, there were four wrong breastmilk errors and one near miss reported.  The Department of Health was involved, and CHP was asked to develop a remediation plan to prevent the occurrence of wrong breastmilk. By replacing manual processes for labeling and delivering breast milk with an EHR-enabled workflow supported by the use of PPID bar code scanning, Children's Hospital has not had a breast milk error since implementation.

Read the Children's Hospital of Pittsburgh of UPMC Breast Milk Labeling Case Study

Using the following tools, Children's Hospital significantly reduced hospital acquired infections, reduce patient safety events, and improve patient throughput in the PACU.

I.T. Support Model

A new I.T. support model was created to meet the needs of the providers and clinicians. The traditional model of calling the helpdesk and waiting for a call back was no longer applicable.  Physicians demanded real time service to real time IT problems.  The new CDT (the Clinical Desktop Team) was designed as a mobile unit specifically to meet the user’s need for fast and efficient technical resolutions.  This is an on-time support model for clinical areas.  There are five technicians who round continually, have wireless phones and laptops, and wear backpacks that have tools and parts.  These individuals are knowledgeable about the clinical application and technology.  They round with new providers, they respond within minutes or seconds to calls, and they can be depended upon to meet the needs of the clinical users. 

I.T. Infrastructure

CHP was simultaneously building a new hospital while building the EHR.  This allowed the hospital to be built with an I.T. infrastructure to support robust wireless technology, adequate cabling and wall ports for connectivity.  In addition to infrastructure, a device refresh program was adopted for PCs, COWs, and mobile devices to ensure that I.T. components were refreshed before end of life. 


iAware – Critical Care dashboard

iAware was developed in partnership with the EHR vendor, Cerner.  iAware is the solution to the paper chart used in the critical care areas.  The real-time data is displayed from the EHR in a format that the physicians designed to be effective for their workflow.  There are screens above the patient beds that show real-time data of patient data attributes.  The clinician can choose the attributes that display; however, the following are the most common:

  1. Patient weight, age, allergies
  2. Medication orders
  3. Heart rate in conjunction to medication dosage that may affect the heart rate
  4. Inputs and outputs
  5. Vitals
  6. Lab tests
  7. Respiratory data

Read Children's Hospital of Pittsburgh of UPMC's examples of how utilizing health IT improved clinical care.

Medical Device, Davies, electronic health record, diabetes, Medication Management