Medical Professional Publications

zero hero

If you’ve been to a Vision Forum recently, or you’ve noticed some new buttons being sported by your colleagues, then you know something about Zero Hero. This is the name for the hospital’s new Quality and Safety effort, which is being spearheaded by Chief Medical Officer Dr. Rich Brilli. Dr. Brilli is challenging Nationwide Children’s to eliminate preventable harm by 2013. So what is preventable harm? Who’s a Zero Hero? And why does every single employee at Nationwide Children’s need to care about this? Zero Hero 

Q. Let’s start with the basics, what is preventable harm?
Preventable harm occurs when a series of preventable errors or mistakes reach a patient and have a negative impact on him or her. Examples include medication errors, falls and blood stream infections. The patient didn’t come to the hospital to be treated for this, but they are now facing a new complication at best, and sadly in the most severe cases preventable harm can even result in death.

Q. Why aspire to zero – that seems almost impossible – why not a 50 percent reduction?
I can’t justify aiming to reduce harm by only a percentage. How do we explain to our patient families that we strive to only reduce a portion of preventable harm incidents? Mothers and fathers don’t care that we have 50 percent fewer cases of harm when their child is on the receiving end of ventilator-associated pneumonia. Aiming to be “the best” or “have the lowest rate” says that it is still acceptable to have some preventable harm. I reject that, we need to stop thinking about percentages and start thinking about number of actual patients harmed. When you look at it that way, one is too many. Our patients and families deserve a zero aspiration.

Q. I am in a non-clinical department, how does this affect me?
It affects you just as much as it affects the doctors and nurses seeing patients every day. Since the entire staff of Nationwide Children’s is one team, we must all work together to achieve our goal. If you work in billing or with patient medical records, you have the ability to prevent medical record numbers being duplicated, which could cause harm at the bedside. If you work in the hospital and you walk past a spill and do nothing, you’re enabling a preventable error that could hurt a patient or family member in a fall. Every single employee has a duty and a responsibility to create a safe day, every day by being a Zero Hero.

Q. What will you do to help us reach zero?
I have asked a team of consultants, HPI, to work with us to identify areas for improvement and put in place new systems to achieve zero preventable harm. These changes will include a set of individual behavioral expectations that will make safety a core value for each one of us. Our goal is to provide all the resources and necessities this hospital needs to reach zero. I don’t expect you to do this on your own; we’re already one of the best children’s hospitals for safety, but we’re not at zero yet. That’s why these consultants will help us identify the missing pieces.

Q. You talk about Don’t Hurt Me as being a patient family’s first priority.
Yes.  Thankfully most families never even have to consider that this is their priority.  They are concerned with “Cure Me” and “Treat Me With Respect,” but when their child is harmed as a result of preventable errors, suddenly “Don’t Hurt Me” is the most important consideration.

Q. Do you really think this can be done? Or are we being set-up for failure?
I do believe this is possible. I don’t deny it will be a challenge, but we are capable of reaching this goal. By working as one team – no matter what your position title is – we can create a culture that prevents these incidents. As long as we are reducing the number of preventable harm incidents, we are not failing. We have to keep the bigger picture in mind and aim high – well, low in this case. We are the first pediatric hospital to aspire to such a goal, which is great motivation to reach zero.

Q. It’s not like we try to do harm and we have systems to prevent it now – what will change?
First of all, our outlook must change. Right now, it is commonly accepted that medicine can be a dangerous thing and that sometimes outcomes aren’t favorable. The biggest change will be to hold ourselves to a higher standard and stop accepting that it happens and start believing it can be prevented. To err is human, we will never eliminate all errors, however we can and we must put systems in place that catch those errors before they reach our patients. 

Q. Will there be training?
Yes. Every single member of staff will be going through training. Management has worked with HPI to develop a safety package for all staff to use in this endeavor.

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Nationwide Children's Hospital
700 Children's Drive Columbus, Ohio 43205 614.722.2000