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Responsive Learning and Proactive Harm Prevention: Development of a Tiered Event Review Continuum
Orysia Bezpalko1, Stephanie Powell1, Elena Becker2
1Center for Healthcare Quality and Analytics.
Journal of Patient Safety
|June 30, 2026
Summary
A new tiered event review system reduced harm in hospitalized children by combining retrospective and proactive safety reviews. This quality improvement initiative achieved high reliability and yielded significant insights for patient safety.
Area of Science:
- Pediatric patient safety
- Healthcare quality improvement
- Hospital-acquired conditions (HACs) management
Background:
- Despite progress, preventable harm persists in hospitalized children.
- Integrating retrospective and proactive safety frameworks can enhance harm reduction efforts.
- A comprehensive, standardized approach is needed to learn from and prevent harm events.
Purpose of the Study:
- To develop and implement a standardized, tiered event review continuum for hospitalized children.
- To optimize learning from and prevention of harm events.
- To enhance patient safety through a multiyear quality improvement initiative.
Main Methods:
- Utilized quality improvement methodologies for a multiyear initiative.
- Developed a standardized approach to HAC reviews, incorporating retrospective and proactive elements.
- Tracked adherence, attendance trends, and longitudinal outcomes post-implementation starting in 2017.
Main Results:
- Completed 2217 retrospective reviews (2017-2023) with 95% adherence.
- Conducted 1286 proactive reviews (Jan 2022-June 2024).
- 75% of patients undergoing proactive reviews did not experience subsequent harm events.
Conclusions:
- Successfully developed and implemented a reliable tiered event review framework.
- The framework spans retrospective and proactive safety approaches, yielding system-level insights.
- Future work includes enhancing provider engagement and measuring longitudinal impacts of safety huddles.
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