Factors Related to Serious Safety Events in a Children's Hospital Patient Safety Collaborative

Area of Science:

• Pediatric Patient Safety
• Healthcare Quality Improvement
• Health Services Research

Background:

• Serious safety events (SSEs) are infrequent at individual hospitals, hindering trend identification for patient care improvement.
• Patient safety organizations facilitate trend analysis and cross-institutional learning for pediatric patient safety.
• The Child Health Patient Safety Organization (CHILDPSO) supports learning across children's hospitals.

Purpose of the Study:

• To describe longitudinal trends in SSE rates among CHILDPSO member hospitals.
• To identify the sources of harm associated with SSEs in pediatric care.

Main Methods:

• Analysis of SSE data reported to CHILDPSO from 44 children's hospitals (January 1, 2015–December 31, 2018).
• SSEs were classified by severity and grouped into categories and subgroups.
• Contributing factors were tagged for each event, with subgroups <5 events excluded.

Main Results:

• A decrease in the 12-month rolling average SSE rate per 10,000 adjusted patient days from 0.71 to 0.41 (P < .001).
• Of 830 SSEs, 21% were high severity; 67% were patient care management events (e.g., diagnosis/treatment errors, medication errors, care coordination issues).
• Lack of situational awareness was the most common contributing factor (17.9%), linked to 20% of high-severity SSEs.

Conclusions:

• Hospitals collaborating through CHILDPSO demonstrated a reduction in SSEs.
• Patient care management represented the most frequent category of SSEs.
• Future research should investigate contributing factors and develop risk mitigation strategies for pediatric patient safety.