Quality improvement initiative to reduce serious safety events and improve patient safety culture.
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 10000 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.
Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 USA. stephen.muething@cchmc.org
Stephen E
SE
Muething
Anthony
A
Goudie
Pamela J
PJ
Schoettker
Lane F
LF
Donnelly
Martha A
MA
Goodfriend
Tracey M
TM
Bracke
Patrick W
PW
Brady
Derek S
DS
Wheeler
James M
JM
Anderson
Uma R
UR
Kotagal
D002648:Child; D003299:Cooperative Behavior; D006776:Hospitals, Pediatric; D006786:Hospitals, Urban; D006801:Humans; D007318:Inservice Training / Q000592:standards; D033183:Interdisciplinary Communication; D019300:Medical Errors / Q000517:prevention & control; D009820:Ohio; D009937:Organizational Objectives; D061214:Patient Safety / Q000592:standards*; D058996:Quality Improvement / Q000592:standards*; D017751:Safety Management / Q000592:standards*; D012941:Social Responsibility