Every morning at C.S. Mott Children’s Hospital, 40 to 50 people gather for our 15-minute safety huddle. It’s an opportunity for staff to share safety concerns that can range from equipment issues to challenging family situations with the potential to cause safety issues. It’s not the place where we solve the concerns, but it’s a place for concerns to be voiced and connections to be made so issues can be addressed. After the huddle, a quick email recap is sent out to more than 250 staff members.
One issue that was quickly resolved as an outcome of a safety huddle was a compatibility problem we had when we changed IV tubing vendors. The new tubing was supposed to work with the old tubing, but we quickly realized that wasn’t the case. One person raised it at a safety huddle. Others shared that they too were having problems. We were able to quickly replace all the old tubing with new tubing and avert any patient safety issues before they even occurred.
Ensuring patient safety starts with a culture focused on problem solving, not assigning blame. We need to be aware of safety issues in order to address them, and we need a culture where staff at any level are not hesitant to voice concerns. In addition to our safety huddles, we have an online form staff can use to submit safety concerns. They know they can voice their concerns without fear of being labeled a troublemaker.
Since we opened the new hospital and renewed our focus on a culture that encourages voicing safety concerns, we’ve nearly tripled the number of safety reports submitted. That doesn’t suggest that more unsafe practices are occurring. It’s evidence that our staff has patient safety as a primary concern and are always seeking opportunities for improvements that can help.
All safety reports go to our risk management department and to the manager of the area where the report was filed. The management team follows up to identify opportunities for improvement. We also share that information across the hospital in situations where changes in equipment or procedures can be of benefit in other areas.
On a monthly basis, we also take a careful look at any incidents that may have caused harm to a patient. That careful examination allows us to identify what went wrong and how we can improve to avoid similar situations in the future. It’s crucial that we acknowledge that healthcare is delivered by humans who can and do make mistakes. Our goal is to have the systems and processes in place to keep the frequency and severity of those mistakes down. And, that’s exactly what we are accomplishing with these patient safety initiatives.
Take the next step:
- Learn about how we’re standardizing medications to keep patients safe.
- See how the U-M infusion pharmacy uses technology to keep patients safe.
Chris J. Dickinson, MD, is a pediatric gastroenterologist and Chief Medical Officer at C.S. Mott Children’s Hospital. Dr. Dickinson has been deeply involved in several safety and quality initiatives throughout the entire health system. In his role as Chief Medical Officer, he focuses on achieving new safety and quality standards in C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital.
University of Michigan C.S. Mott Children’s Hospital is consistently ranked one of the best hospitals in the country. It was nationally ranked in all ten pediatric specialties in U.S. News Media Group’s “America’s Best Children’s Hospitals,” and among the 10 best children’s hospitals in the nation by Parents Magazine. In December 2011, the hospital opened our new 12-story, state-of-the-art facility offering cutting-edge specialty services for newborns, children and women.