Cincinnati Children's Blog

Patient safety … a journey, not a destination

December 1, 2009

Standing in front of an auditorium full of bright-eyed (given the early-morning hour, that is) medical residents and other doctors today delivering Grand Rounds, I wanted to convey to them that they’re in a special place. The title of the talk was “A Patient Safety Update: Can Cincinnati Children’s Become a High Reliability Organization?”

Steve Muething, MD, aka Dr. Steve: It's not for a lack of desire that we fall short of our patient safety goals

I know many of them are exhausted. And I know medical education/residency can be overwhelming. But Cincinnati Children’s has made incredible progress in providing the highest quality care and I want them to feel good about that.

And yet, we need them to also know that our work in patient safety is a journey, not a destination. We’ll never “be there.” We’ll always be on the way.

So we keep working at it.

Some of what I shared with the audience is not easy to look at. I told them about past “serious safety events” that our patients have suffered in the past few years. Serious safety events are either so-called “never events” – things that should never happen – or deviations from standard practices or errors that result in severe harm. From a wrong-site surgery to a delayed diagnosis; from a medication error to a suicide. This is hard. But it’s important to emphasize that these are real issues, real lives … real children entrusted to our care.

I also share the successes. I told them that we have eliminated “preventable codes” outside of the intensive care unit. We’re “nearing elimination” of ventilator-acquired pneumonia. And while we haven’t yet hit our goal for serious safety events, we’ve made progress: progress that translates into 33 fewer patients harmed these past three years than if we’d done nothing to reduce those mistakes.

We’re taking giant steps toward better outcomes and (even though this wasn’t our original goal) lower costs. That’s the good news. We’re going to keep working on it.

How did we get this far? It hasn’t been easy. We’ve spent a lot of time looking at other industries, trying to figure out what has worked in, for instance, the airline business to prevent accidents. We try new things and we measure everything we do. All of this is part of the journey to be what’s known in the trades as a “high reliability organization.”

We’ll share some more details later.

Stephen Muething, MD, is a Pediatrician and Associate Professor at the University of Cincinnati and Cincinnati Children’s. He has recently taken on a leadership role as Vice President of safety at Cincinnati Children’s because of his experience in design for reliability and high reliability organizations.


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