Nursing Manager Rainbow Babies and Children's Hospital, United States
Abstract:
Introduction: While strategies to achieve the aspirational goal of zero harm vary across pediatric heart centers, the foundation of a successful approach relies on the underlying safety culture. Team members must feel safe raising and discussing medical errors without fear of reprisal. In addition, real and potential risks (‘good catches’) must be reported to affect change.
Objective: To create a safety culture in which interdisciplinary pediatric cardiac care team members are engaged and empowered to report medical errors and identify perceived risks to not only patients and their families but also themselves and their colleagues.
Methods: An interdisciplinary, multimodal approach to fostering a culture of safety was launched in late 2020. Interventions have included weekly Leader Walk Rounds, monthly Safety Boards (Heart Center, ICU, and stepdown unit), and a daily Heart Huddle. Leader Walk Rounds brings Heart Center leadership to the bedside to discuss safety from both the perspective of what is going well as well as areas for improvement. Safety Boards provide center-wide and local unit forums to review ‘big picture’ safety concerns, discuss trends, and brainstorm initiatives. The Heart Huddle provides a daily opportunity for team members to share safety concerns and operational risks in an interdisciplinary forum that includes leadership. Alignment for improvement and impact across the global program are discussed. Frontline team members and operational leadership enter safety risks and events into an institutional reporting system. Rates of reporters identifying themselves, good catches, and events resulting in patient harm are analyzed and reported monthly. Safety culture is assessed by increased rates of reporters identifying themselves and reporting of potential/theoretical safety issues (good catches).
Results: Since the launch of our comprehensive Heart Center safety program, good catch and reporter-identified percentages have increased with a concomitant decrease in the percent of reported incidents causing patient harm. The total number of Heart Center reports per month has increased by 50% (2021 mean: 40 reports/mo; 2022 mean through July: 60 reports/mo) with census and acuity stable. The rate of both reporter-identified incidents (Figure) and 'good catches' (currently averaging 50%) have increased.
Conclusions: A comprehensive patient safety program aimed at establishing a culture of safety is essential to reducing patient harm. An empowered and engaged staff is a key component to developing and fostering initiatives that provide open and transparent discussion of actual and perceived risks within a team-focused forum that encourages transparent interaction among frontline providers and leadership. Creating and supporting an environment of nonpunitive reporting is key in the journey for the aspirational goal of zero harm.
