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  • Publication # 13-RA008

Quality improvement initiative reduces serious safety events in pediatric hospital patients

Patient Safety and Quality

During the last 10 years, hospitals have implemented a variety of systems to improve their safety culture. Nevertheless, serious safety events (SSEs) continue to occur. Such events can lead to increased length of stay and mortality among children being treated in the hospital. As these events are deemed preventable, new interventions are needed. 

Recently, researchers at Cincinnati Children’s Hospital Medical Center used a quality improvement initiative focused on cultural and system changes that resulted in a significant and sustained reduction of SSEs and an improvement in the overall patient safety culture. Central to the initiative was the creation of a SSE reduction team that reviewed safety literature and the 35 most-recent SSEs that occurred at the hospital. The researchers also interviewed more than 100 leaders, physicians, and staff to get their opinions. Interventions included error prevention simulation training and the use of volunteer safety coaches to reinforce safety behaviors. A variety of tactical interventions were also developed for high-risk areas, such as the operating room and intensive care unit. Other processes implemented included establishing a patient safety oversight group with regular reviews of root cause analyses of every SSE and sharing of lessons learned across the organization. 

After the multipronged quality improvement intervention was implemented, the number of SSEs declined significantly from an average of 0.9 to 0.3 per 10,000 adjusted patient-days. In addition, the length of time between SSEs grew from an average of 19.4 days to 55.2 days, even with an increase in patient volume. Overall, the patient safety culture improved as evidenced by positive responses from staff. The study was supported by AHRQ (HS16957). 

See "Quality improvement initiative to reduce serious safety events and improve patient safety culture," by Stephen E. Muething, M.D., Anthony Goudie, Ph.D., M.S.P.H., Pamela J. Schoettker, M.S., and others in the August 2012 Pediatrics 130(2), pp. e423-e431.


Page last reviewed May 2013
Internet Citation: Quality improvement initiative reduces serious safety events in pediatric hospital patients: Patient Safety and Quality. May 2013. Agency for Healthcare Research and Quality, Rockville, MD.


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