James M. Anderson Center for Health Systems Excellence

  • Use High Reliability Methods to Eliminate Serious Harm

    We will eliminate all serious harm by leveraging our internal and external learnings toward becoming a high reliability organization (HRO) by June 30, 2015 

    At Cincinnati Children’s, our aim is to become a highly reliable system of anticipation and containment that eliminates serious harm. When we began our journey we made a  decision to eliminate harm, beginning at the top of the “harm pyramid”; that is, to begin with the most severe harm first. 

    Pyramid of Harm.Our reasoning was that by focusing on the most acute harm, we would capture and hold the focus of the organization, start ourselves on the path of what must be a relentless journey, and most importantly, aim our sights on the cause of the most suffering and worst outcomes. 

    Over the last five years, our focus on serious safety events (SSEs) has resulted in a more than 80 percent reduction of our SSE rate and was achieved through transparency about our outcomes, a predisposition toward action and fundamental improvements to key areas including safety governance (our board and executives took on accountability for safety), leadership behaviors, error prevention programs, methods of conducting cause analysis, tactical interventions and our ability to spread changes across our system in response to events.   

    As part of our 2015 strategic plan, we have expanded our focus beyond SSEs to include all serious harm.  Though there is no formal definition of serious harm, Ohio’s pediatric hospitals have described it to include: 

    • Serious safety events
    • Surgical site infections
    • Ventilator-associated pneumonia
    • Bloodstream infections
    • Catheter-associated urinary tract infections
    • Adverse drug events (levels 6-9)
    • Pressure ulcers (grades 3-4)
    • Serious falls
    • Codes outside the ICU
    • Serious peripheral IV infiltrates 

    Our approach to eliminating serious harm includes achieving high reliability on our processes, developing a high reliability organizational culture and leveraging human factors design to further reduce the probability of error.  

    Equally important is our participation in the Ohio Children’s Hospitals Solutions for Patient Safety learning network, a partnership among the state’s eight children’s hospitals and the business community aimed at improving the quality of care delivered to children in Ohio and reducing healthcare costs. 

    Our participation allows us to learn not simply from our own experiences, but from those of others so that the entire system is improved by the advances of any one institution.  This network allows Cincinnati Children’s to fulfill its mission of spreading knowledge while also keeping us focused on the importance of learning from others.