Most employees are familiar with the CHAMP safety behaviors that are part of Yale New Haven Hospital's high reliability organization (HRO) effort.
There's another component of HRO that is less visible, yet critical to the hospital's success in reducing patient harm. The Serious Events Review Committee (SERC) is a 15-member group of nurses, physicians, hospital leaders, quality improvement staff and others. The group reviews root-cause analyses and corrective action plans for serious safety events – those resulting in preventable patient harm – and oversees efforts to correct problems and prevent future events.
"Our aim is not to place blame on people or departments," said Ohm Deshpande, MD, director, Care Management, who co-chairs the committee with Ena Williams, RN, vice president, Patient Services. "A high reliability organization has a culture of improvement, not a culture of blame."
The committee receives reports about serious safety events in different ways. Many come from employees who use the RL Solutions online event reporting system. Employees and physicians may also notify unit or department leaders of an event; and the hospital's daily Morning Safety Report highlights potential serious safety events soon after they occur.
A team of patient safety experts reviews each report to determine if the case meets criteria for a serious safety event, and if so, classifies its level of severity. The SERC has standardized follow-up procedures for serious safety events. Within 45 days post-event, the department (or departments) involved conducts a root-cause analysis to determine exactly how the event occurred. The department then develops a corrective action plan to fix any system problems that caused or contributed to the event. The SERC reviews all action plans, presents them to hospital leadership and works with department leaders to ensure that approved plans are sustainably implemented to prevent future safety events.
"In the past, action plans stayed at the department level," said Theresa Vander Vennet, RN, JD, assistant general counsel, Risk Management, who facilitates the SERC. "The Serious Events Review Committee oversees events that occur throughout the hospital and can share action plans to help prevent those events in other areas."
One serious issue the SERC saw occurring in different areas of YNHH involved recording accurate patient weights, which often affect medication dosing. Medication errors, along with falls with injury and wrong-site procedures, are the most common causes of serious safety events at YNHH. Through root-cause analysis and action plans, the hospital instituted changes to procedures and Epic to ensure accurate weights are recorded in patients' records.
Changing procedures and Epic are just part of the solution, Williams noted. "To prevent many errors, you have to change behaviors and create that culture of safety," she said. "That takes time."
