Shared Learning from Potentially Preventable Events

Background: In our summer 2019 SPS site visit, we learned from another hospital about their potentially preventable event (PPE) process and modified this to fit our institution’s needs and culture. Objective: We aimed to catalog and share learnings across the institution from a variety of predefined PPE types. Methods: From July 19, 2020 to February 3, 2020, our PPEs (40% VAE, 28% CLABSI, 19% unplanned extubations, 7% PIVIE, 2% fall, 2% pressure injury) were shared across the institution. Our team includes information from the charted bundle compliance as well as the apparent cause analyses and root cause analyses (both the discussion and the anonymous surveys sent to team members about any opportunities that may exist). Each PPE includes a short description of the event and a bulleted list of “lessons learned” which are shared in our monthly quality meeting, in safety coach meetings, and in leader communications. Select PPEs are shared in our leader communications as a potential story with which to begin their meetings, in our weekly standard shift huddle template for all units, and in our bimonthly in-person Children’s Hospital Event Review. Results: The use of this tool serves to condense our events and stories into a succinct “lessons learned” for all care team members and to be sure our leaders are aware of every predefined PPE. Conclusions: Our SPS site visit led us to pursue this useful tool at no additional cost, which has helped us organize and share our lessons learned with our care team members.Fig. 1.: Fishbone (ishikawa) diagram of apparent causes and lessons learned from potentially preventable events over 1 year.