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Yale New Haven Children's Hospital gets to zero


Among those celebrating one year without a serious safety event at Yale New Haven Children's Hospital were (l-r): Cynthia Sparer, senior vice president, Operations, and executive director, YNHCH; Clifford Bogue, MD, chief medical officer; Rebecca Ciaburri, RN, performance manager; Thomas Balcezak, MD, chief medical officer, YNHH; Lauren Edwards, RN, performance improvement coordinator; and Matthew Grossman, MD, quality and safety officer.

There was nothing to celebrate at Yale New Haven Children's Hospital on Jan. 23, and staff, physicians and leaders turned out to mark the special occasion.


Staff members joining in the celebration included, back row (l-r): Sandra Anyoha, RN, patient service manager, and Heather Parrott, RN, assistant patient service manager, Short Stay and Neurosciences and Medical Specialty units; and Thomas Martin, APRN, service line educator, PICU and PACU. Front row (l-r) are: Andrea Brown, RN, assistant patient service manager, and Stacey Rose, RN, service line educator, Pediatric Medicine, Cardiology, and Pediatric Surgery; and Karen Kalbfeld, RN, service line educator, Pediatric Hematology/Oncology.
In this case, "nothing" was a good thing; the crowd of people who attended an event at YNHCH were celebrating one year without a single serious safety event. On the way to becoming a high reliability organization, it's a major milestone, but it took some stops and repairs along the way, said Matthew Grossman, MD, quality and safety officer, YNHCH.

"The way you improve safety is by fixing little problems," he said. "It takes time."

Since January 2014, with the launch of the Children's Hospital Morning Safety Report (MSR), YNHCH leaders and safety and quality physicians and staff have focused on creating a culture that encourages employees to report potential and actual safety issues using the RL Solutions online event reporting system. Safety issues are also shared at the Children's Hospital's MSR – which is modeled after the Yale New Haven Hospital-wide daily Morning Safety Report.

During YNHCH's 15-minute morning report, representatives from every inpatient and outpatient area have an opportunity to bring up safety concerns that occurred in the past 24 hours or could occur in the next 24. YNHCH's safety and quality team investigates all issues reported through RL Solutions and the MSR, analyzes the events to identify ways to reduce future harm and informs staff of the results. "There has been steady feedback from leadership to frontline staff about what specifically has been done to address their safety concerns," said Rebecca Ciaburri, RN, performance manager, quality and safety, YNHCH. "There is no question that the engagement of frontline physicians and staff is the reason we are able to celebrate one year without a serious safety event."

The feedback has had a ripple effect. The number of RL Solutions reports from YNHCH has tripled, to about 700 a month. With increased reporting and the feedback on outcomes, staff have become more aware of situations that can lead to safety problems. As a result, the number of great catches – employees stopping safety events before they cause serious harm, has skyrocketed, Ciaburri said. The Children's Hospital has also seen a 40 percent shift from precursor events (those that reached the patient, but caused minimal or no harm) to near-miss events (those that were caught before reaching the patient).

Despite YNHCH's success this past year, the commitment to eliminate patient harm is stronger than ever, Dr. Grossman said.

"This is just a start. We have a long way to go."