Children's Hospitals Today - Spring 2018 - 24

FEATURE / QUALITY AND SAFETY

Safety is everyone's job
Simple but thoughtful interventions can change a hospital's
culture and have a substantial effect on patient safety.
By Darcie Reeson

A

child came to Yale New Haven
Children's Hospital on 21 medications; she was inadvertently sent
home on 20. The missing medication
was aspirin, and she had a stroke. It's
a story that has stayed with Matthew
Grossman, M.D., quality and safety
officer, and his team, for years. Team
members still tell it when talking about
their work to prevent serious safety
events (SSEs). "This oversight caused
harm to one of our patients," Grossman
says. "That sticks with you. It's the top
line of our jobs to prevent these kinds
of things from happening."
Grossman, along with Rebecca
Ciaburri, B.S.N., RN, performance
manager, developed Reducing Serious

24

CHILDREN'S HOSPITAL S TODAY Spring 2018

Safety Events in a Children's Hospital,
a project that won Children's Hospital
Association's 2017 Pediatric Quality
Award. The four-year effort established a baseline rate of SSEs for the
first time at the hospital and subsequently reduced that rate-through
improved reporting-to zero.
SSEs, a deviation from a generally
accepted practice that leads to moderate or severe patient harm, are the
most fundamental way to determine
how safe a hospital is. In 2012, Yale New
Haven Children's set its sights on being
among the safest children's hospitals in
the country. But the hospital had a cumbersome system that left many events
unreported, according to Grossman.

"We couldn't answer the question about
how safe we were," he says. "And we
knew events were being swept under
the rug or just considered a complication. It was the place to start."

Anything can lead to a
serious safety event
Events with the potential to cause
harm can look different with every
report. "What are the common mistakes that lead to a big safety event?
They could be anything," Grossman
says. "And that's the idea behind this
project. We wanted to know about everything that happened and address
issues that could lead to harm."
A concept that moved Grossman



Table of Contents for the Digital Edition of Children's Hospitals Today - Spring 2018

Contents
Children's Hospitals Today - Spring 2018 - Intro
Children's Hospitals Today - Spring 2018 - Cover1
Children's Hospitals Today - Spring 2018 - Cover2
Children's Hospitals Today - Spring 2018 - Contents
Children's Hospitals Today - Spring 2018 - 2
Children's Hospitals Today - Spring 2018 - 3
Children's Hospitals Today - Spring 2018 - 4
Children's Hospitals Today - Spring 2018 - 5
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Children's Hospitals Today - Spring 2018 - Cover3
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