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New Solutions for Patient Safety

Monday, March 12, 2018 - 08:30

Since 2012, safety interventions are estimated to have spared more than 9,000 children from serious harm caused by medical errors in nearly 130 hospitals across the United States and Canada, reports Children’s Hospitals’ Solutions for Patient Safety (SPS).1

SPS is a collaborative network of children’s hospitals that share a vision to eliminate serious harm among hospitalized children. The interventions also have saved an estimated $148 million in health care costs.1

“One child harmed is too many,” says Daniel Hyman, MD, Chief Medical and Patient Safety Officer at Children’s Hospital Colorado, which is part of the SPS network. “We’re moving closer and closer to zero harm,” he says.

Establishing a culture of safety and learning to prevent errors has helped his hospital reduce the rate of serious harm to patients by two-thirds, he says. The network leadership notes that the keys to such significant harm reduction are three-fold: improving processes, implementing a safety culture, and analyzing the root cause of errors.

The medical teams collect and share data to track their progress over time and discuss their successes and challenges. They analyze and learn from the data. These collaborations take place during weekly calls as well as during semi-annual in-person training sessions, monthly webinars, password-protected website discussions, process data reports for chief executive officers, and publications highlighting best results.

Transforming an institution’s culture must happen at all levels, Hyman says. Boards of trustees and senior leaders at SPS network hospitals are challenged to transform their organizational culture and set the expectation of personal accountability for safety from all levels of staff within their institutions.  

The network’s work helps all members of interdisciplinary teams speak up by defining what behaviors are acceptable and encouraged, says Trey Coffey, MD, SPS Associate Clinic Director and Associate Professor of Pediatrics at the University of Toronto. “We have a common language,” she says. “If we all get the same training on error prevention, it becomes easier to speak up.”

The SPS coalition helps members discover and correct the root causes of risks. “The proximate cause of an error might be a nurse giving a patient the wrong medicine, but we need to discover the root cause ― why was the error not prevented, or not caught sooner,” Dr. Hyman says. “That kind of analysis is what will help us avoid the same error in the future.”

Participation in the network provides the tools and framework to make patient safety more achievable, Dr. Hyman says. “It makes us all proud to know we’re focused on the right things.”

Trainees and faculty participating in SPS initiatives may be eligible for MOC Part 4 credit from the ABP.