• 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
    • Central line-associated bloodstream infections
    • Catheter-associated urinary tract infections
    • Adverse drug events (levels 6-9)
    • Pressure ulcers (grades 3-4)
    • Injuries from falls and immobility (Currently in Sustain)  
    • Preventable readmissions  
    • Obstetrical adverse events  
    • Venous thromboembolism  
    • Peripheral intravenous infiltration and extravasations

    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 Children’s Hospitals’ Solutions for Patient Safety learning network, a national effort initially funded in part by the federal Partnership for Patients program aimed to help 80-plus children’s hospitals in more than 30 states achieve results by focusing on eliminating specific hospital-acquired conditions and enhancing a culture of safety at their institutions.

    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.