• Article
  • April 27, 2018

New Report: Understanding the Source of Patient Harm

A safety report points to top patient safety vulnerabilities and areas for action.

Children's hospitals have a strong history of making great strides in improving patient safety by working together. The stakes are high—one instance of serious harm can have catastrophic consequences for a child and his or her family. The Child Health Patient Safety Organization (PSO), the nation's only PSO dedicated to children's hospitals, provides a confidential place for children's hospitals to prevent serious patient harm through active surveillance, an early warning system and shared learning.

In this safe community, learning within the PSO is federally protected to promote participation across state lines. Hospitals share opportunities with each other to mitigate harm and improve patient safety.

For every children's hospital, zero harm is the only acceptable patient safety goal. The 2017 Child Health PSO annual report, Perfecting Detection, shows how 60 children's hospitals are sharing information on harm events and learning from each other to identify risks before harm occurs in their organizations.

A new analysis based on reported cases reveals the top safety vulnerabilities for children's hospitals, which health care organizations can use to set future priorities to improve patient safety. The report also includes a review of new pediatric-specific strategies and tools for three high-risk safety topics that have resulted in harm: diabetes care management, thermal injuries and retained foreign objects.

The PSO is continuously monitoring emerging pediatric trends that reveal patient safety risks. The group's intention is to proactively identify risks and alert providers to ensure serious harm isn't repeated.