Cleveland Clinic Children's and Pediatric Institute Outcomes
Serious Safety Events
Serious Safety Events
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
2011 - 2019
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 2017, Cleveland Clinic Children's saw over 50,000 outpatient visits and over 10,000 inpatient admissions.
Four Quarter Moving Average
2011 - 2018
A moving average is a technique to get an overall idea of trends in a data set. Each point on this graph is the average of the four preceding quarters.
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)
- CPOE in Children’s Hospital (2009)
- In Situ and Simulation Lab Mock Codes (2009)
- Pediatric Early Warning System (PEWS) (2010)
- 24/7 Pediatric Pharmacist (2010)
- Double Checks for Medications in NICU (2010)
- All Caregivers - Error Prevention Training (2011)
- Resident Curriculum in Safety (2011)
- Hospitalists 24/7 in house (2011)
- Daily Safety Briefing (2012)
- Family Engagement Team/Healthcare Partners (2012)
- Medication Barcode Technology (2013)
- Escalation of Care guidelines developed (2013)
- OBRT (Obstetric Response Team) (2014)
- Neonatal Emergency Cart For the Pregnant In-patient (2014)
- Team based review of all level 3 or higher ADE’s (2014)
- Implementation of Smart Syringe Pumps (2014)
- VAST Team established (2015)
- Situational Awareness (2015)
- Pharmacy Services ID, Transplant, Epilepsy (2016)
- NICU Web Camera (2016)
- PICU Nurse led rounds (2016)
- Bedside HAC huddles (2016)
- Emergency Transfer Review (2017)
- Preventing CLABSI - Protecting Our Children (2017)