A decade after the publication of the Institute of Medicine report To Err is Human1, health care in the United States continues to cause unnecessary deaths and morbidities.2,3 In the 2002 Agency for Healthcare Research and Quality (AHRQ) report to U.S. Senate Committee on Appropriations regarding medical errors, the most common causes of medical errors were problems with communication, standardization of care, adherence to guidelines and protocols, and information flow between and within service areas.4 That is, the majority of adverse events and medical errors are attributable to poor teamwork and variation in care practices. Consequently, opportunities for errors are greater in high-risk groups, such as pediatric congenital heart surgery patients who receive care throughout a complex system of hospital units provided by a number of multidisciplinary care teams.

This toolkit is presented as a result of Project TICKER, which aimed to implement a patient- and family‐centered safe practice infrastructure for pediatric congenital heart surgery patients by incorporating teamwork training and integrated clinical pathways (ICPs) into the existing program at N. C. Children’s Hospital. During the first phase of the project, health care providers throughout the pediatric congenital heart surgery service line were trained in TeamSTEPPS®. During the next phase, expert panels from each clinical area designed, tested, and implemented ICPs for two congenital heart conditions: ventricular septal defect (VSD) and tetralogy of Fallot (TOF).

A toolkit, as defined by AHRQ, is an action-oriented compilation of related information, resources, or tools that together can guide users to develop a plan or organize efforts to conform to evidence-based recommendations or meet evidence-based specific practice standards. The Project TICKER toolkit combines evidence-based safe practices (TeamSTEPPS and ICPs) in order to have more of an impact than either safe practice by itself.

We divided the toolkit into five main sections: Getting Started, Teamwork, Integrated Clinical Pathways, Measurement, and Lessons Learned. In each section, we provide suggestions for organizing and implementing project activities to address the topic and recommendations based on what we learned. Tools are described and linked throughout the toolkit and listed at the end of each section.

This toolkit is specifically designed for use in pediatric congenital heart surgery programs. However, much of the information and processes we describe could also be relevant (with adaptations) to other pediatric or adult surgical or medical service lines with or without national databases such as adult congenital heart, adult cardiovascular surgery, solid organ transplant, trauma, inflammatory bowel disease, cystic fibrosis, or sickle cell disease programs. In particular, much of the Getting Started section applies to patient- and family‐centered safe practice infrastructures in general. Teamwork training and coaching, as described in the Teamwork section, are applicable for all clinical areas. Finally, the process we present for developing ICPs can be used in various settings, even though the conditions and content of the pathways would be different.


1 Institute of Medicine. To err is human: Building a safer health system. Washington, D.C.: The National Academies Press, 1999.

2 Clancy CM. Ten years after to err is human. Am J Med Qual. 2009 Nov-Dec; 24(6): 525-528.

3 Agency for Healthcare Research and Quality. National Healthcare Quality Report. Report No.: 09-0001. c2008. [cited 2010 January 13]. Available from: http://www.ahrq.gov/qual/qrdr08.htm

4 Agency for Healthcare Research and Quality. AHRQ’s patient safety initiative: Building foundations, reducing risk. Interim report to the senate committee on appropriations. Report No.: 04-RG005. c2003 December. [cited 2010 January 13] Available from: http://www.ahrq.gov/qual/pscongrpt/