Supporting Safer Surgery: System-Level Interventions to Enhance Pediatric Perioperative Safety.

Abstract

Over a 21-month period, a cluster of 13 safety events was observed in a perioperative service area that met criteria as either serious safety events per the health care performance improvement safety event classification system or Joint Commission sentinel events. This cluster of events served as the impetus to deploy high reliability organization (HRO) interventions to reduce potential future harm. To increase safety awareness and improve clinical safety across perioperative services, 3 interventions were iteratively implemented over a 6-month period: (1) surgical safety stand-downs; (2) error prevention training; and (3) establishment of a safety coach program. Simultaneously, analyses were conducted to address systemic causes leading to and preventing additional safety events from occurring. The impacts of these interventions were then monitored for over 2 years post-implementation to assess the outcome. Following the deployment of 3 interventions, we observed an increase in cases between events from a baseline mean of 2977 cases to a period of 39 654 cases (over 585 days) without a safety event triggering analysis. This occurred with a concurrent increased trend in safety reports. As a balancing metric, we did not observe decreased case volumes; in fact, cases increased throughout the observed period. Department-wide HRO-based interventions contributed to a significant decrease in serious safety and sentinel events and should be considered to improve patient care. Attention to departmental safety trends can drive systemic improvements leading to higher-quality perioperative care.