Pediatric Patient Safety: Shared Learning to Improve Patient Outcomes

Two decades ago, the seminal Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine) report To Err Is Human: Building a Safer Health System first highlighted the influence of poorly designed health care delivery systems and suboptimal processes as contributors to patient safety.¹  Substantial progress has occurred since then, including creation of a federally mandated Child Health Patient Safety Organization,²  which uses a standardized taxonomy for patient safety events, contributory factors, and severity of harm,³  with shared learning by dissemination of reports to individual institutions and to the public.⁴  In this issue of Pediatrics, Burrus et al analyze and report on 4 years of serious safety events (SSEs) from 44 Child Health Patient Safety Organization–participating hospitals regarding the types of safety events, severity of harm, and contributory factors.⁵  Their results underscore the overall improvement in pediatric safety in these institutions during...