Saved by zero: Driving down human error
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At best, it seems almost too ambitious, if not outright impossible. Last week, the Obama administration set a goal of eliminating all traffic deaths in America within the next 30 years.

Think about that for a moment. Last year, more than 35,000 people were killed in automobile accidents in the United States, and the numbers continue to rise. In fact, a new report by the U.S. Department of Transportation shows that through the first half of 2016, fatal accidents have actually risen another 10.4 percent over the same period last year.

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Yet, in the midst of all of this, officials are setting an ambitious goal. They aren’t merely hoping to reverse the trend; their goal isn’t to cut the number of deaths by 20 or 30 percent, or even by half. Their goal is total elimination. No fatal accidents. None. Zero.

And that’s exactly what their goal should be.

Why? Because almost all crashes — at least 94 percent — involve human error, and as humans, we are not only capable of changing that, we are obligated.

It’s a subject about which I am extremely passionate. As the chief medical officer of the largest pediatric hospital in America, I have made elimination of human error my priority.

In 2008, I helped launch an initiative at Nationwide Children’s Hospital in Columbus, Ohio, called Zero Hero. It is a safety and quality program that challenged our staff to meet one basic goal: We needed to not only lower the rate of preventable harm and injuries in the children we served, we needed to strive for zero preventable harm events. We were the first pediatric institution in the country to establish such a program and to make it a public goal.

It was a daunting challenge and an audacious goal, but one to which our entire staff was committed. Immediately, we developed and implemented tracking systems to better identify, measure and analyze harm events. We appointed multidisciplinary teams to establish best practices and monitor compliance with these care practice changes.

We standardized safety procedures and held error-prevention training for 9,000 employees. At first, our harm events increased — an apparent increase — as staff began to report and identify events that, in the past, had not been reported. Within a year, we started seeing results.

Over the ensuing 18 months, Ohio’s Children’s Hospitals banded together to reduce surgical site infection and medical errors, and subsequently, emboldened by strong results in these domains, the children’s hospitals aspired to eliminate serious harm across the entire state of Ohio. Ultimately, this statewide collaborative network formed the Ohio Children’s Hospitals Solutions for Patient Safety. Across the state, we saw marked reductions in surgical site infections and medication errors and began to see decreases in other forms of serious harm.

Today, more than 100 children’s hospitals across the United States have joined the movement to eliminate serious harm in their hospitals. Sharing experiences and outcomes data, debating best practice procedures and striving for zero instances of preventable harm, together we continue to make remarkable strides.

This national network of children’s hospitals has significantly lowered harm events in multiple conditions, such as hospital-acquired infections, pressure injuries, adverse drug events, and ventilator-associated pneumonia, among others.

Since 2012, through May of 2016, we have saved 6,686 children from serious, preventable harm, which has led to an estimated savings of more than $121 million dollars in medical costs. That’s an average of saving more than four children from harm and more than $76,000 in costs every day, and each month, we continue to see consistent improvement.

We still have work to do, of course. Though we’re extremely proud of the differences we have made, our goal is not to lower instances of preventable harm — the goal is to eliminate them.

When we first initiated the Zero Hero program, some suggested that perhaps zero was too ambitious. Instead, they suggested that we revisit our goals and perhaps strive to be “the best” at quality and safety, or “have the lowest rate” of preventable harm cases.

I disagreed, and much like Transportation Department officials are doing through their recent announcement to strive to eliminate all traffic deaths, I insisted that we stop thinking in terms of percentage improvement and instead start thinking about actual numbers of patients who are harmed.

When you look at it that way — and only when you make zero your ultimate goal — you realize that even one victim is one too many. The goal of zero patient preventable harm was once viewed as heretical and it is now a common safety goal across more than 100 children’s hospitals. Based upon our experience in pediatric healthcare, I strongly applaud the Obama administration for setting such an audacious goal. I believe it is the right goal, because even one preventable traffic-related death is one too many. We can do this!

Dr. Richard J. Brilli, MD, FAAP, MCCM, is chief medical officer at Nationwide Children’s Hospital in Columbus, Ohio. 


 

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