How Children's National Health System is doubling safety event reports through quality initiative

After Washington, D.C.-based Children's National Health System was challenged to increase its voluntary safety event reports submitted over a three-year period, a quality initiative at the pediatric health system more than doubled its number of reports, according to a study published in Pediatric Quality & Safety.

To examine quality and safety data in real time improve outcomes for patients, Children's National formed the initiative, called "10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System."

A multidisciplinary team identified three major areas for improvement, including how difficult is it to report an event, whether staff thought they may be in trouble for reporting and whether they thought their report made a difference.

The team then created interventions to increase reporting. Through this initiative, the health system praises staff for safety "catches" and views these reports as a chance to build on what went well or look for areas to improve as opposed to creating an environment where employees are punished for reporting these events.

The study found the number of safety event reports at Children's National rose from 4,668 in fiscal year 2014 to 10,971 in fiscal year 2017. Additionally, the median amount of time to submit event reports dropped by roughly 30 percent, anonymous reporting decreased by 69 percent, and the number of reports submitted only as "other" decreased from a baseline of 6 percent to 2 percent.

"Children's National Health System's focus on increasing safety event reporting resulted in increased organizational engagement and attention," the study authors concluded. "This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals."

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