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 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.

FIGURE 1

Key driver diagram for reduction in SSEs. A key driver diagram describes the learning structure for a quality improvement project and includes the aim statement, key drivers, and change strategies to be tested or implemented during the project. The aim statement is developed by using SMART (specific, measurable, actionable, relevant, and time-bound) goals and states the primary objective of the project. The key drivers are the elements believed to be crucial to achieving the goal. OR, operating room.

FIGURE 2

Number of SSEs per 10 000 adjusted patient days. Patient-days were adjusted to include inpatient admissions, ED visits, and short stays. LCL, lower control limits; UCL, upper control limits.

FIGURE 3

Days between SSEs. LCL, lower control limits; UCL, upper control limits.