Joint Topic: Error Prevention — Tier Zero: Preventing Harm Before it Happens (201-2)

3:30 – 4:30 pm Thursday, October 28

The care of the pediatric patient with cancer is complex. Patients are at increased risk of harm from falls, central line infections, thrombosis, and pressure injuries resulting from the treatment they receive. The Harm Prevention Program at our organization provides a structure and processes for identifying and reviewing patient harm events.

The program qualifies events of harm as preventable adverse clinical outcomes. The definition and criteria for events of harm are standardized, as is the process for follow-up and information sharing after the event. A Tier One huddle occurs immediately following identification of any event of harm, with the intent to create awareness and mitigate any immediate risk to the patient. A Tier Two is a thorough review held within days to weeks following the harm event. Both Tier One and Tier Two huddles have had a great impact in retrospective evaluation and consideration of prevention strategies. However, harm prevention requires a more proactive approach, recognizing that some events, specifically central line–associated bloodstream infections (CLABSIs), are not wholly unexpected by the clinical care team. Oncology leadership developed a new process known as a Tier Zero—a proactive huddle designed to mobilize harm prevention efforts using the Tier One and Tier Two framework but occurring before any recognized harm. The Tier Zero offers the team time to anticipate potential events of harm before they occur and to put prevention strategies in place for any patient with a high probability for a harm event to occur. Preoccupation with failure is a core tenant of our organization. The Tier Zero process allows us to detect emerging patient safety failures, mitigate the risk to prevent harm, and view learnings as opportunities for future preventive efforts.