An Effective Learning Framework for Preventing Harm

Health care teams are deeply committed to protecting children from harm and ensuring the safest possible outcomes. Yet despite best intentions, harm can happen. 

Every child who enters a hospital begins a complex journey. Risks of harm can hide in any part of the chain of care, in any one of the hundreds of steps taken from the moment a patient arrives to the moment they make it home safely. When hospitals keep to themselves, they risk repeating errors others have made or have learned to prevent. When they share knowledge, they avoid preventable harm.

That’s why Congress passed the Patient Safety Act in 2005, leading to a new and unique kind of organization in health care called a Patient Safety Organization (PSO) — a place where hospital data can be collected, aggregated, and analyzed without fear of liability because of federal confidentiality protections. 

“There is nothing more effective at collectively improving harm prevention in pediatric care,” said Sandip Godambe, MD, PhD, chief medical officer of Rady Children’s Health Orange County. “It means we can learn from missteps, not hide them. There is no other venue where hospitals can feel safe doing that.”

In 2019, the Office of Inspector General found that nearly all general acute-care hospitals that partner with a PSO view the collaboration as beneficial. Among these hospitals, 80 percent reported that the PSO’s insights and analysis of patient safety events have been critical in helping prevent similar incidents. There are now more than 100 federally registered PSOs across the country. Only one is focused solely on children’s safety.

The Children’s Hospital Association (CHA) Child Health PSO, made up of nearly 60 children’s hospitals spanning 30 states, has spent the last decade honing a learning framework that can serve as a model for others. It has analyzed more than 2,800 events, issued 4,253 early warnings, held more than 200 case learning events, shared 17 patient safety alerts, and developed a variety of practical resources for hospitals. 

With nearly 100 percent of its members contributing data from safety events, the PSO’s learning framework has become a reliable system for identifying pediatric hazards early, and providing mitigation strategies before harm occurs.

“At the center of it all are children and their families,” said Dr. Godambe, who is also co-chair of the Child Health PSO. “It’s a medication error prevented. A diagnosis clarified. A process redesigned so the next patient’s journey is safer than the last.”

Three Core Elements of an Effective Framework

Though all PSOs have confidentiality protections, none of them function exactly the same. The Child Health PSO’s framework for shared learning involves three core elements: 

1. Data Sharing: The engine of PSO is the submission of safety events by member hospitals. Serious harm in children's hospitals is rare, so aggregating these events from nearly 60 children's hospitals provides a broad view of risks. The Child Health PSO analyzes the reports, identifies patterns, and highlights priorities. These inform the PSO’s programming and products, and hospitals can easily find the deidentified analysis in an online repository and view specific action plans for mitigating the risks. 
2. Weekly Huddles: Every week, hospitals join a multi-center safety huddle modeled after daily safety calls at hospitals. The calls provide awareness and early warning of potential harm and a forum to ask for advice on specific challenges. This approach evolved out of years of pilot testing and iterating, and was validated with a five-year retrospective study. Year after year, members find this the most valuable part of participating in the PSO. 
3. Recurring Presentations: Twice a month, members present a case example of a safety event in a webinar format and have a discussion afterward. Yearly, the PSO hosts a conference where members hear from thought leaders in the safety industry and share presentations of their own.

Together, these three elements create a learning system that turns individual experiences into collective wisdom. And this wisdom doesn’t stay with the hospitals that participate. Because children receive care in all settings, the PSO spreads the word through publications, safety warnings, alerts, risk assessments, and toolkits.

Case Study: Diagnostic Toolkit

In 2018, the PSO team noticed a troubling trend. More than half of children’s hospitals reported communication failures as a top contributor to diagnostic errors, the second-leading cause of harm. 

In response, the PSO created a diagnostic toolkit. Built from aggregated data, expert input, and member feedback — all made possible by the federal protections given to PSOs — the toolkit gives hospitals structured ways to improve communication during the diagnostic process. 

The core component of the toolkit, a diagnostic timeout template, ensures the care team takes a moment to evaluate their diagnosis and that no voice is left unheard in the diagnostic process.

CHA’s quality improvement (QI) team led a pilot to test the timeout’s usability and value using a QI approach. “There are not many applied interventions like this in the literature. This is among the first,” said Elise Buckwalter, MSN, CPNP-AC, CPHQ, CHA’s clinical quality improvement consultant who led the pilot.

The toolkit has been accessed in 19 countries, showing that lessons learned by a few can improve care across the globe.

The Power of PSOs 

With a PSO, hospitals don’t need to experience harm to learn from it. By using the unique protections provided to PSOs, safety efforts progress faster and farther. 

When a member reports a case, others benefit. When a huddle reveals a new risk, hospitals across the country act on it. Toolkits, warnings, and best practices informed by voluntary reporting empower all hospitals to get ahead of harm.

But it takes more than the existence of a PSO; it takes a reliable framework of shared learning so no safety event ever occurs twice — and ultimately, no preventable harm occurs at all. 

Emily Tooley, MSN, RN, CPPS, CPHQ, is senior director of patient safety at the Children’s Hospital Association. 

Photo by rawpixel.com on Freepik

The Children’s Hospital Association presented at the IHI Forum in 2025. Details about how to submit a session proposal or poster for the 2026 IHI Forum are available here.

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