The implementation of a new safety principle focuses less on what goes wrong and more on what goes right.
Nationwide Children's Hospital launched Zero Hero in 2009 as part of the hospital's quality and safety efforts. Its goal was to eliminate preventable patient harm and achieve a zero-error rate. The hospital expanded its quality improvement infrastructure to accommodate more than 150 harm-related projects and saw a dramatic decrease in its preventable harm events—earning it a 2013 Pediatric Quality Award.
Since that time, Nationwide has continued its march toward zero preventable harm by achieving a 50% reduction in all patient harm events, including:
- 500 fewer harm events compared to its peak.
- 225 fewer serious safety events since Zero Hero's launch.
- A serious safety event occurrence rate of just one every 122 days—compared to a rate of once every 12 days prior to Zero Hero.
- A three-month stretch in 2018 with no adverse drug events level 5-9 despite administering more than 200,000 doses per month.
The sharp decline in patient harm events presented a unique—albeit enviable—challenge for Nationwide Children's. "You don't improve until after something has happened, but if we want to get to zero we want to stop these things from happening in the first place," says Thomas Bartman, M.D., Ph.D., associate medical director of quality improvement at Nationwide Children's Hospital in Columbus, Ohio. "Another issue is that as you become better at preventing past errors, the small trickle of problems you do have end up being one-offs."
This paradox helped pave the way for a new approach in the hospital's quest for zero—Safety-II.
Safety-II concept focuses on successful events
The idea behind Safety-II is to shift focus away from preventing things from going wrong (the conventional thinking around safety, referred to as Safety-I) to instead emphasize on ensuring things go right. In realigning the approach to patient safety by concentrating on why processes occur correctly in high-performing units—as opposed to why processes fail—the aim of Safety-II is for safety management to not only be reactive but proactive as well.
The concept was originally put forth in a 2013 whitepaper and is gaining some traction across various industries. Among children's hospitals, Nationwide Children's says it's an early adopter of the concept following a 2018 study Bartman co-authored around the hospital's pediatric intensive care unit (PICU)—a unit that had experienced fewer adverse drug events than other units at Nationwide Children's.
"We conducted interviews with PICU staff and a number of the things they were saying were very consistent with the Safety-II philosophy even though they hadn't read the literature or even heard of Safety-II—it was just something they were doing organically," Bartman says. "We've tried to learn from that, capitalize on it and develop a new program to get others in the institution thinking and working in that way."
Nationwide in early stages of implementation
Nationwide Children's is still relatively early in its Safety-II journey, according to Bartman. They've tested the concept in a few smaller units with Plan-Do-Study-Act (PDSA) cycles and are currently conducting an educational and training blitz to bring staff up to speed on Safety-II concepts.
"The concepts of monitoring, anticipating, responding and learning are the cornerstones of the Safety-II theory," Bartman says. "We're trying to develop tools so that everyone gets those concepts and improves in all four of those processes."
Staff feedback is positive
Bartman says staff feedback on Safety-II has been largely positive—particularly among more experienced clinicians who prefer to rely on their training and experience rather than rigid protocols when treating patients.
"People appreciate being told they don't have to follow every rule 100% of the time," Bartman says. "If you have a good reason to do it, you're doing it in a thoughtful way and you're collaborating with others to make sure you've chosen the right time to break the rule—there have to be some guardrails in place, but I think people are receptive to that concept."
Advice for hospitals interested in Safety-II
Nationwide Children's expects to be able to share more learning soon from its Safety-II implementation, Bartman says. And for children's hospitals looking to begin rolling out the new concepts now?
"Put people on your implementation team who are your innovators—people who think outside the box," Bartman says. "And try to come up with a way to implement it in your institution that works for you—the same approach may not work at all children's hospitals."
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