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A Systems Approach to Spread Improvements from Safety Events

PIPSQC is pleased to highlight the recent publication in Pediatric Quality and Safety, entitled "A Systems Approach to Spread Improvements from Safety Events."

For more information or to download the abstract, please visit:


Sustaining and spreading improvement efforts following safety events are essential to eliminate similar events. Sustaining improvements can reduce repeat events from occurring in the same environment, but spreading effective improvements to prevent similar risks in other areas was a persistent challenge in our institution despite efforts to improve awareness.

To design, test, and execute a spread process to eliminate similar harm events across the organization.

The safety team established a global aim, developed a key driver diagram, mapped an ideal-state process, and tested interventions using PDSA cycles. Interventions included:
- Initial safety event teams identified action items from their improvement plans to consider for spread to other environments with similar risks.
- Leaders of potential spread areas completed risk assessments to evaluate if the identified risks were applicable, if the initial improvements fit the proposed spread area, to determine the burden in adopting the changes, and finally to assess the urgency of the proposed change.
- Synthesized risk assessments into recommendations to an oversight committee.
- Supported area leaders in planning of spread of work endorsed by the oversight committee or referred for further evaluation.
- Tracked spread of identified items.

A total of 18 specific action items were evaluated for spread. Nine items were adopted for spread, three items required further, ongoing evaluation, and four items were abandoned (Fig. 1). Adopted and abandoned spread items were distributed broadly across service lines (Fig. 1).

Structured identification of and subsequent assessment of risk facilitated by an institutional safety team supported by an institutional oversight body drove successful adoption of a majority of spread items. Fit, urgency, and burden are key attributes that impact adoption. Ongoing partnership with area leaders and monitoring will be critical to increase sustained adoption of spread safety improvements. Subsequent work will assess the system-level impact on outcomes.