Jul 13, 2018 Our Journey to Becoming a High Reliability Organization

At Children’s Specialized Hospital, we’re committed to building a high reliability performance culture to provide the safest possible care for patients.

Every patient is entitled to health care that is safe, reliable, and effective. However, despite decades of efforts to improve patient safety, medical errors are responsible for up to 250,000 deaths in the U.S. a year, making these errors the third leading cause of death.doctor checking person's blood pressure

At Children’s Specialized Hospital, we’re committed to building a high reliability performance culture to provide the safest possible care for patients. Simply put, becoming a highly reliable organization (HRO) is recognizing that most incidents of potential harm, rather than the error of a single individual, are signs of likely multiple flaws in the system. We call these incidents precursor events, or ‘near misses.’ Our responsibility is to recognize these incidents as red flags and use them to prevent similar errors from occurring or evolving into more serious issues.

For example, a pharmacist prepares a medication in a unit dose form. The medicine is placed in a bag that’s labeled for a different medication. When it is brought to the patient care unit, the floor nurse scans it with bar code technology and realizes it’s the wrong medication. The error is corrected and no harm is done.

In institutions not focused on high reliability, this near miss might be forgotten. But an HRO will study it carefully to analyze why this happened and implement evidence-based protocols to avoid future incidents.

Children’s Specialized Hospital has been on this safety journey for several years. For the last year and a half, we’ve participated in a larger system journey as part of RWJBarnabas Health. Partnering with HPI Press Ganey, a leader in health care reliability, RWJBarnabas Health launched “Safety Together,” an initiative to reduce errors and harmful incidents through high reliability. This initiative is being rolled out to all RWJBarnabas facilities.

“Safety Together” provides training for all hospital staff—physicians, nurses, therapists, aides, pharmacy and lab workers, as well as nonclinical team members: those in finance, security, administration and other areas. While these employees may have limited patient interactions, their work contributes in a real way to the safety of patients and staff.

All employees, including our physicians, will take a four-hour course taught by members of our leadership team under the guidance of HPI Press Ganey. The training, conducted like seminars, encourages open dialogue, questions and discussion. A series of error prevention tools is presented and participants learn how to use these tools to create a safer work environment. Our commitment is to create opportunities to reinforce and practice these tools so our entire team develops a skill level and expertise with their use.

Communication is a critical part of this process: asking questions and speaking up for safety whenever the potential for error is identified. For many years, Children’s Specialized has embraced the concept of a fair and just culture. This creates a comfort level where reporting errors and near misses is celebrated, not penalized. Regardless of their title or discipline, employees recognize we’re building accountability for following policies and procedures.

The training is offered at all 13 of our sites to make attendance convenient. We’ve now trained almost half of our employees and our goal is to have more than 95% trained by the end of the year. Training will not be limited to one course but will be an ongoing process.

Our goal is nothing less than zero incidents of preventable harm through process improvement. It is an ambitious undertaking, but one that is vitally important for the safety and well being of our patients, staff, and community.