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Aiming for Zero

April 28, 2014

Efforts to eliminate preventable harm in pediatric care are making progress. But can we make it to zero?

In October 2008, Richard Brilli, MD, stood in a silent conference room, waiting for his audience to digest the news he’d just delivered: hundreds of significant harm events are identified each year at Nationwide Children’s Hospital, and nearly every one of them could be prevented.

The group before him, the institution’s board of directors, knew that incidents of preventable patient harm are an unfortunate reality in the health care industry. But hearing the numbers aloud made the reality all the more real.

Conversations such as this were happening in hospital board rooms across the country at the time, a reaction to the 1999 Institute of Medicine (IOM) report To Err is Human, a 287-page study that found between 44,000 and 98,000 people in the United States die each year in hospitals from preventable medical errors. This report was among the first to publicize the serious consequences associated with medical errors.

The response to the report was fast and fierce. News media reported the figures. Congress convened hearings and health care industry leaders testified about plans to reduce the numbers. But it wasn’t long before the furor quieted and things appeared to go back to business as usual.

A handful of hospital executives, Dr. Brilli among them, were not content to let the issue die. As the chief medical officer at Nationwide Children’s, Dr. Brilli felt strongly that the problem couldn’t be addressed on a national scale until individual institutions tackled the problems from within. So in 2008, he found himself convincing the board of directors that just reducing the number of serious harm events wasn’t enough. The goal, he argued, had to be eliminating them altogether.

TO ERR IS HUMAN

When the IOM report was published, many leaders in the industry decried its findings, says Paul Levy, former president and chief executive officer of Beth Israel Deaconess Medical Center in Boston.

“The first thing hospitals and health care leaders often say when a report like this comes along is that the data are wrong,” Levy says. “Or, they may say, well maybe the data aren’t wrong but our numbers are higher because our patients are sicker.”

In 2007, Levy, now retired, became the first hospital executive in the country to report all of his hospital’s quality and safety data on its intranet, despite resistance from his staff and board. At first, Levy says, they feared posting the data would drive patients away. But his co-workers soon embraced the idea.

“The value of the transparency is that it holds us accountable to the standard of care that we believe in,” Levy says.

ONE TOO MANY

Despite the success at Beth Israel Deaconess, few other adult hospitals in the country followed suit. Indeed, Levy says, the first move toward transparency and eliminating patient harm came in the pediatrics field, with Ohio paving the way.

In early 2009, the state’s eight pediatric institutions, including Nationwide Children’s, launched the Ohio Children’s Hospitals’ Solutions for Patient Safety, a nonprofit network whose initial focus was on reducing surgical site infections and adverse drug events. Today, the organization has a much broader mission and reach, with 78 member children’s hospitals around the country.

The same year the network launched, Nationwide Children’s also unveiled “Zero Hero,” the patient safety initiative that traces its beginnings to Dr. Brilli’s impassioned 2008 board presentation. In the program’s first year, nearly 9,000 employees underwent comprehensive safety training. In 2011, Nationwide Children’s became the first pediatric institution in the country to make its serious safety event statistics public.

“Health care outcomes are only going to improve if everyone is willing to change long-standing habits and do that consistently, and being transparent is an important part of that,” Dr. Brilli says. “Health care has had a culture of secrecy for decades and I’m not proud of that. But I am proud of the fact that we at Nationwide Children’s and now other children’s hospitals around the country are focusing on improving outcomes and sharing data more transparently than ever before.”

Five years after the program’s official roll-out, “Zero Hero” has resulted in an 83.3 percent reduction in serious safety events, a 78 percent decrease in other serious harm and a 25 percent drop in hospital mortality. Getting to these results is a laudable effort, Dr. Brilli says. “But there’s always room for even greater improvement.”

As if to underscore his point, a study published in September 2013 in The Journal of Patient Safety reported that the number of patient deaths in the United States due to medical errors may actually be between 210,000 and 440,000, as much as five times higher than the IOM estimate. When the latest report was published, some health care executives once again questioned the data. But that, Dr. Brilli says, really isn’t the point.

“Even one incident of preventable harm is too many.”