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      Serious Experience Events: Applying Patient Safety Concepts to Improve Patient Experience

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          Abstract

          Pediatric healthcare systems have successfully decreased patient harm and improved patient safety by adopting standardized definitions, processes, and infrastructure for serious safety events (SSEs). We have adopted those patient safety concepts and used that infrastructure to identify and create action plans to mitigate events in which patient experience is severely compromised. We define those events as serious experience events (SEEs). The purpose of this research brief is to describe SEE definitions, infrastructure used to evaluate potential SEEs, and creation of action plans as well as share our preliminary experiences with the approach.

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          Most cited references12

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          A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality.

          To evaluate the effectiveness of a hospital-wide initiative to improve patient safety by implementing high-reliability practices as part of a quality improvement (QI) program aimed at reducing all preventable harm. A hospital wide quasi-experimental time series QI initiative using high-reliability concepts, microsystem-based multidisciplinary teams, and QI science tools to reduce hospital acquired harm was implemented. Extensive error prevention training was provided for all employees. Change concepts were enacted using the Institute for Healthcare Improvement's Model for Improvement. Compliance with change packages was measured. Between 2010 and 2012, the serious safety event rate decreased from 1.15 events to 0.19 event per 10 000 adjusted hospital-days, an 83.3% reduction (P < .001). Preventable harm events decreased by 53%, from a quarterly peak of 150 in the first quarter of 2010 to 71 in the fourth quarter of 2012 (P < .01). Observed hospital mortality decreased from 1.0% to 0.75% (P < .001), although severity-adjusted expected mortality actually increased slightly, and estimated harm-related hospital costs decreased by 22.0%. Hospital-wide safety climate scores increased significantly. Substantial reductions in serious safety event rate, preventable harm, hospital mortality, and cost were seen after implementation of our multifaceted approach. Measurable improvements in the safety culture were noted as well. Copyright © 2013 Mosby, Inc. All rights reserved.
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            Children’s Hospitals’ Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm

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              Quality improvement initiative to reduce serious safety events and improve patient safety culture.

              Many thousands of patients die every year in the United States as a result of serious and largely preventable safety events or medical errors. Safety events are common in hospitalized children. We conducted a quality improvement initiative to implement cultural and system changes with the goal of reducing serious safety events (SSEs) by 80% within 4 years at our large, urban pediatric hospital. A multidisciplinary SSE reduction team reviewed the safety literature, examined recent SSEs, interviewed internal leaders, and visited other leading organizations. Senior hospital leaders provided oversight, monitored progress, and helped to overcome barriers. Interventions focused on: (1) error prevention; (2) restructuring patient safety governance; (3) a new root cause analysis process and a common cause database; (4) a highly visible lessons learned program; and (5) specific tactical interventions for high-risk areas. Our outcome measures were the rate of SSEs and the change in patient safety culture. SSEs per 10000 adjusted patient-days decreased from a mean of 0.9 at baseline to 0.3 (P < .0001). The days between SSEs increased from a mean of 19.4 at baseline to 55.2 (P < .0001). After a worsening of patient safety culture outcomes in the first year of intervention, significant improvements were observed between 2007 and 2009. Our multifaceted approach was associated with a significant and sustained reduction of SSEs and improvements in patient safety culture. Multisite studies are needed to better understand contextual factors and the significance of specific interventions.
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                Author and article information

                Journal
                J Patient Exp
                J Patient Exp
                JPX
                spjpx
                Journal of Patient Experience
                SAGE Publications (Sage CA: Los Angeles, CA )
                2374-3735
                2374-3743
                23 May 2022
                2022
                : 9
                : 23743735221102670
                Affiliations
                [1 ]Ringgold 6429, universityLucile Packard Children’s Hospital – Stanford; , Stanford Children’s Health, Palo Alto, CA, USA
                [2 ]Department of Pediatrics, Stanford University, School of Medicine, Palo Alto, CA, USA
                [3 ]Department of Radiology, Stanford University, School of Medicine, Palo Alto, CA, USA
                [4 ]Departments of Radiology & Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
                Author notes
                [*]Lane F Donnelly, Lucile Packard Children’s Hospital – Stanford, Stanford Children’s Health, The Barn, 700 Welch Rd. Suite 125 (Room #104), Palo Alto, CA 94304, USA. Email: lane.f.donnelly@ 123456gmail.com
                Author information
                https://orcid.org/0000-0003-1882-3518
                Article
                10.1177_23743735221102670
                10.1177/23743735221102670
                9134394
                6758ca6b-0feb-440c-a912-057f908694fa
                © The Author(s) 2022

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                Categories
                Patient Experience Research Brief
                Custom metadata
                ts19
                January-December 2022

                patient experience,patient safety,serious experience events

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