a picture is worth a hundred unintended errors

How are you different? How do I know that you, my patient, should receive this medication and not the one for that patient? How do I keep your information from accidentally showing up in another patient's medical record?

Children's Colorado asks these kinds of questions every day as it aims for zero preventable harm events.

Over the last couple of years, Dan Hyman, M.D., Children's Colorado's Chief Quality Officer, has led an initiative ingenious in its simplicity: add the patient's photo to every medical record. Pediatrics recently published his research.

The advent of these photographs has thwarted an error that surfaces when a caregiver placing orders in one medical record believes he or she is in another.

The idea, Dr. Hyman said, sprang from "the hospital's culture that says, 'that's not good enough. We can fix that.'" In this existing culture, he explained, multi-disciplinary teams examined the nuances of every error and how it occurred, pinpointing the moment when things went awry.

When information travels to the wrong record, for example, the caregiver is perhaps toggling between charts. With the new system, each child's picture appears saliently on a verification screen every time a provider signs an order for a test or treatment.

As a result of the photo implementation, Children's Colorado went 15 months without a patient (who had a picture in his or her medical record) receiving a wrong test or treatment due to an erroneously placed order. Since implementation, there have only been two such errors in more than two years.

VIDEO: See how Children's Colorado touched lives in 2012

Sometimes being better at what we do means learning from others. From a national collaborative of 80 children's hospitals came the idea of conducting daily safety briefings. Seven days a week, leaders throughout Children's Colorado convene to identify, discuss and resolve issues that can affect patient safety or hospital operations.

*Pediatric Intensive Care Unit