No harm should ever be repeated. Driven by that goal, children's hospitals are working together through the Child Health Patient Safety Organization (PSO) to understand—and avoid—serious patient harm. As part of this confidential learning network, more than 50 children's hospitals are now reporting safety events to the PSO each month. The events are aggregated, spurring members to conduct investigations in their individual hospitals and apply recommended practices that reduce the risk of similar harm.
This early warning system is getting results. Here are examples of how children's hospitals have used the experiences of their peers in the PSO to change the way they approach patient safety issues.
Reporting ventriculoperitoneal shunt valve malfunction
When a ventriculoperitoneal shunt revision due to a valve malfunction was reported, PSO members immediately took action to determine their hospital's risk. One hospital shared how this information was useful: "Within 24 hours, we confirmed the product was used in our hospital and notified neurosurgeons of the risk. They weren't aware of the issue and appreciated the information so they could monitor patients potentially at risk for shunt malfunction."
Improving event investigations
After a serious event occurred, one hospital's quality leader recognized the PSO reported a similar event. "This was addressed with my CEO—we meet every two weeks to review safety concerns. Knowing another children's hospital experienced this enabled leadership to focus on the system issue rather than what appeared to be a competency issue. This will impact how the event is investigated for action, improves effectiveness of implementation and saves time and resources."
Including retained foreign objects in surgical checklist
Through analysis of events reported to the PSO, one team recognized factors contributing to retained foreign object. "Some retained items were not traditionally included in an instrument count, such as small Raney clips," says the hospital's vice president of quality and safety.
"Also, devices used during surgery may be modified to accommodate our smaller patients, and if there is a device failure, it may not be recognized that a portion of the device was left behind." The hospital has now focused attention on systems and processes to eliminate retained foreign objects as a repeat harm event.
Assessing reattempted suicide event
An event was reported during intake of psychiatric patient who attempted suicide but was reportedly not suicidal. Discussion in the community ensued on how suicidal versus other psychiatric complaints are distinguished and how processes vary. One hospital reported as a result of this discussion, a risk assessment was conducted in the emergency department to understand vulnerabilities.
These topics are also featured in Patient Safety Alerts, which are shared broadly by the PSO and inform members and the industry of known vulnerabilities in pediatric patient care. In early March, a new alert and risk assessment tool was released to prevent thermal injuries. Learn more about the Child Health PSO.
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