• Report
  • December 15, 2020

Resilience in Action: Child Health Patient Safety Organization 2020 Annual Report

Children’s hospitals are positioned to proactively assess and mitigate preventable harm and become more resilient institutions.

Improvements in patient safety are accelerated by learning from instances of patient harm and anticipating what could go wrong. Participating in the Child Health Patient Safety Organization (PSO) supports both. By understanding events that lead to patient harm at peer institutions, children’s hospitals are positioned to proactively assess and mitigate preventable pediatric patient harm and become more resilient institutions. Because we learn together, children are spared preventable harm.

The engagement of children’s hospitals through the PSO learning network has been remarkable over the past year—a period of unprecedented health care delivery disruption. The overall case learning composite measure increased by 7% to achieve 46% of children’s hospitals being highly engaged in the PSO (see figure 1). This composite measure reflects 54% of children’s hospitals submitting two or more cases over the last year, a 10% increase from 2019. It also includes more than doubling the Safe Table attendance highly engaged metric.

The highest standard of engagement in weekly Safety Huddles (the PSO’s early warning system), 80% attendance, was achieved by 65% of children’s hospitals, which doubled engagement from the prior year. Sixty-one percent of participating children’s hospitals achieved the highest standard in huddle reporting, providing a richer learning system for all to anticipate potential harm. Each organization’s engagement is summarized in a hospital-specific report available as a companion to this annual report.