Quality Improvement Initiative to Reduce Serious Safety Events and Improve Patient Safety Culture

Abstract

BACKGROUND AND OBJECTIVE: Many thousands of patients die every year in the United States as a result of serious and largely preventable safety events or medical errors. Safety events are common in hospitalized children. We conducted a quality improvement initiative to implement cultural and system changes with the goal of reducing serious safety events (SSEs) by 80% within 4 years at our large, urban pediatric hospital. METHODS:A multidisciplinary SSE reduction team reviewed the safety literature, examined recent SSEs, interviewed internal leaders, and visited other leading organizations. Senior hospital leaders provided oversight, monitored progress, and helped to overcome barriers. Interventions focused on: (1) error prevention; (2) restructuring patient safety governance; (3) a new root cause analysis process and a common cause database; (4) a highly visible lessons learned program; and (5) specific tactical interventions for high-risk areas. Our outcome measures were the rate of SSEs and the change in patient safety culture.RESULTS: SSEs per 10 000 adjusted patient-days decreased from a mean of 0.9 at baseline to 0.3 (P , .0001). The days between SSEs increased from a mean of 19.4 at baseline to 55.2 (P , .0001). After a worsening of patient safety culture outcomes in the first year of intervention, significant improvements were observed between 2007 and 2009. CONCLUSIONS: Our multifaceted approach was associated with a significant and sustained reduction of SSEs and improvements in patient safety culture. Multisite studies are needed to better understand contextual factors and the significance of specific interventions. Pediatrics 2012;130:e423-e431 AUTHORS:

Changes in Efficiency and Safety Culture After Integration of an I-PASS–Supported Handoff Process

“…There is ample evidence that links culture of safety to reductions in preventable harm and mortality. [26][27][28] Improvements in safety culture have also been associated with reductions in adverse events within hospitals. 29 Yet, only a few reports have described quality improvement initiatives associated with shifts in safety culture over time.…”

Electronic Health Record Identification of Nephrotoxin Exposure and Associated Acute Kidney Injury

“…22 Statistical process control methodology has served as the primary quality improvement assessment measurement to track the serious safety event rates for the past 7 years at CCHMC. 23 …”

Health professionals’ perceptions of pediatric patient safety culture

“…Although the parents' presence during hospitalization is recommended since it contributes to the promotion of the child's health and well-being and the quality and safety of care (Sanders, 2014), the parents or guardians are often unable to be constantly present at their children's side, impeding an additional protection that would minimize the occurrence of some errors. Muething et al (2012) emphasized that adverse events are common in hospitalized children, increasing the length of hospital stay, the in-hospital mortality rate and the total costs. Although safety culture is a variable that can be isolated, analyzed and changed, the studies performed within this scope in pediatric settings are virtually non--existent (Poley, Starre, Bos, Dijk, & Tibboel, 2011).…”