Tackling delivery system causes of patient harm is no easy feat. A focus on detection ensures that harm is identified, investigated, reported and analyzed. Then action can be taken to address vulnerabilities that will mitigate these risks to patients. The quest to perfect detection has resulted in over 1,000 serious safety event cases reported by children’s hospitals participating in Child Health PSO.
This report highlights 10 patient safety concerns that have high potential for repeat harm, beginning with the PSO’s inaugural safety alert on NG tube misplacement. Other topics include medication safety, communication failures, behavioral health and diagnostic errors. Use the report to review safety issues, assess organizational risks and take action.