Responsive Learning and Proactive Harm Prevention: Development of a Tiered Event Review Continuum

Efforts to reduce health care-associated conditions (HACs) have increased over time, with notable success. Still, opportunities remain to reduce preventable harm in hospitalized children. The integration of both retrospective and proactive safety frameworks can enhance these efforts. We aimed to optimize our ability to learn from and prevent events of harm in hospitalized children at the Children's Hospital of Philadelphia by developing and implementing a comprehensive, standardized tiered event review continuum.

Using quality improvement methodologies, we launched a multiyear initiative to develop a standardized approach to HAC reviews, incorporating learning from events after they occur and proactive planning for at-risk patients before harm events. Measures included adherence to process, analysis of attendance trends, and longitudinal outcomes following reviews. Data were analyzed following full implementation of the review process, beginning in 2017.

From 2017 to 2023, 2217 retrospective reviews were completed with an adherence rate of 95%. Attendees were captured across disciplines, with a majority representing nursing. One thousand two hundred eighty-six proactive reviews were completed from January 2022 to June 2024; of these, 75% of patients did not experience a subsequent harm event during their hospitalization.

We successfully developed and implemented a tiered event review framework that spanned the continuum of retrospective and proactive approaches to safety. This structure has been fully implemented with high reliability across all inpatient areas, and has yielded important insights in patient-level, unit-level, and system-level HAC improvement efforts. Future directions include enhancing provider engagement and better capturing the longitudinal impact of proactive safety huddles on patient outcomes.