Despite major investments of money, lime, and effort, patient safety in the United States has seen little improvement. This is because there are many types of adverse events that harm patients, and their underlying causes are extremely heterogeneous. The past approach of addressing one type of harm at a time will result in very minor and slow improvements in overall safety. In addition, it is difficult to detect and measure errors, causation is ambiguous, and care is provided by multiple professions who tend to function autonomously. Also, the vast variety of diseases, medications, and technology add a level of complexity that is beyond the scope of traditional approaches to improving safety. Most U.S. healthcare organizations have unsuccessfully tried to address patient safety with a top-down approach as they respond to an overwhelming number of externally mandated safety practices which ignore the Wisdom of frontline caregivers, create cultures that emphasize accountability over learning, and in the end, only address a fraction of the harm that occurs. Frontline caregivers must be trained and engaged in all aspects patient safety measurement and improvement. The goal of University of Texas at Houston (UTH) Patient Safety Learning Laboratory (UTPSLL) is to create an environment of collaborative learning focused on reducing all-cause preventable harm by 50% in the neonatal intensive care unit (NICU). Five cores of experts in; 1) Robust Process Improvement (methods of Lean, Six Sigma, and change management); 2) electronic health records; 3) parent engagement; 4) patient safety measurement; and 5) project administration and leadership will collaborate with clinician leaders, frontline caregivers, and parents from Memorial Hermann Health System NICUs to reduce all preventable harms.
Our multidisciplinary team of experts, frontline providers and parents will collaborate in the UT Patient Safety Learning Laboratory to design, develop, and implement innovative interventions to redesign care in neonatal intensive care units and reduce by 50% all-cause preventable harms to infants.
