Pediatric Patient Safety: Shared Learning to Improve Patient Outcomes.

Abstract

Two decades ago, the seminal Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine) report To Err Is Human: Building a Safer Health System first highlighted the influence of poorly designed health care delivery systems and suboptimal processes as contributors to patient safety.1 Substantial progress has occurred since then, including creation of a federally mandated Child Health Patient Safety Organization,2 which uses a standardized taxonomy for patient safety events, contributory factors, and severity of harm,3 with shared learning by dissemination of reports to individual institutions and to the public.4 In this issue of Pediatrics, Burrus et al analyze and report on 4 years of serious safety events (SSEs) from 44 Child Health Patient Safety Organization–participating hospitals regarding the types of safety events, severity of harm, and contributory factors.5 Their results underscore the overall improvement in pediatric safety in these institutions during the study period as demonstrated by a downward trend in SSEs from 0.71 to 0.41 per 10 000 adjusted patient days. The strengths of this study are the learnings from a collaborative, which can be disseminated publicly, the spectrum of harm among the reported SSEs (with one-fifth of SSEs having the highest severity defined as death or permanent harm), and the identification of more important contributory factors, such as lack of situational awareness. However, the study results also reveal there is still much to be done to mitigate pediatric patient harm.Organizations must continue to implement strategies to eliminate harm related to procedures (eg, retained foreign objects, wrong procedures). Recently there has been controversy regarding the pursuit of zero harm because it might lead to provider burnout, which can lead to harm and increased health care costs.6 Regardless, as stated by the legendary football coach Vince Lombardi, “Perfection is not attainable, but if we chase perfection we can catch excellence.” Hospitals need to remain laser-focused on all causes of preventable patient harm, especially those resulting from procedures, medications, and other products and devices. There are also important lessons to be learned from non-SSEs that were excluded from this analysis.Furthermore, patient safety needs to be understood in the context of the care setting. Several studies have revealed that certain settings such as emergency departments, operating rooms, and ICUs are more prone to safety events. Indeed, several reports from the federally supported pediatric research network Pediatric Emergency Care Applied Research Network highlight the types, contributory factors, and severity of harm in the context of pediatric emergency care.7–10 Finally, as the number of procedural events and medication errors decrease, the hidden impact of missed, delayed, or wrong diagnosis was justifiably identified in the Burrus et al article. Diagnostic errors have been considered for a long time as the “blind spot” in patient safety and the National Academies of Sciences, Engineering, and Medicine report Improving Diagnosis in Health Care highlighted that most individuals will experience at least 1 diagnostic error in their lifetime, sometimes with devastating consequences.11 Similar to other safety events, diagnostic safety needs standardized taxonomy, validated and accepted definitions, and robust study designs, including prospective, multicenter studies to understand the epidemiology, contributory factors, severity of harm, and impact of interventions to mitigate harms.12 Ultimately, patient safety (avoidance of negative outcome) and quality (achievement of positive outcome) need to be at the center of all health care services. The imperative to support multidimensional approaches to reduce patient harm, including research, education, training, and policy, has never been greater.