Pediatric Quality, Safety, and Patient Experience

Pediatric Institute Serious Safety Events

2022

A serious safety event occurs when we deviate from generally accepted performance standards (either not doing something we should have or doing something that shouldn't have been done) and cause significant patient harm (death, moderate, or severe permanent harm or significant temporary harm).

Pediatric Serious Safety Events

2017 - 2022

The Y-axis on this graph represents serious safety events and the X-axis represents time. Each bar represents the total number of serious safety events that occurred in a given quarter¹.

¹In 2020, Cleveland Clinic Children's saw over 50,000 outpatient visits and over 10,000 inpatient admissions.

Our goal is zero harm

Having a common set of error prevention tools and incorporating situational awareness into our everyday operations has helped us come this far. We are continually working to inculcate high reliability principles into all our operations to achieve our goal of zero harm.

What are we doing to improve?

· Family Activated PMET (2008)

· Family Centered Rounds (2008)

· Safety Rounds (2008)

· Ohio Children’s Hospitals Solutions for Patient Safety (2009)

· 24/7 Pediatric Pharmacist (2010)

· All Caregivers - Error Prevention Training (2011)

· Resident Curriculum in Safety (2011)

· Hospitalists 24/7 in house (2011)

· Daily Safety Briefing (2012)

· Medication Barcode Technology (2013)

· Escalation of Care guidelines developed (2013)

· Family Engagement Team/Healthcare Partners (2014)

· OBRT (Obstetric Response Team) (2014)

· Implementation of Smart Syringe Pumps (2014)

· VAST Team established (2015)

· Situational Awareness (2015)

· Bedside HAC huddles (2016)

· Preventing CLABSI - Protecting Our Children (2017)

· “What a Catch Program” (2019)

· UPDATE – Situational Awareness Vital Electronic Scout (SAVES) at Main Campus (2019)

· Individualized Behavioral Health Plan (2020)

· Visual Management Tools (2021)

· Escalation of Care Campaign (2021)

· SAVES implemented at Regional Hospitals (2022)