Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?
Study design: Single-institution quality-improvement initiative.
Setting: Cincinnati Children’s Hospital Medical Center.
Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.
SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).
This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.
Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.
Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.
Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.