HACs (pronounced “hacks”) are complications, infections or other unintentional mistakes that happen when a patient is in the hospital for care. For example, a patient is given the wrong medication or wrong dosage of the right medication, leading to complications and sometimes even death.

Other types of HACs include infections at the incision site from surgeries, pneumonia caused by ventilators or urinary tract infections from catheters.

Root of concern

For far too long, the health care industry took for granted that because health care was, for the most part, delivered by humans, that human error was unavoidable. However, what we know now from several years of working collaboratively across hospital, state and international borders is that many HACs are, in fact, preventable.

"A patient is given the wrong medication or wrong dosage of the right medication, leading to complications and sometimes even death."

We also know that HACs cannot be eliminated simply by a “checklist” that clinicians follow. Patient safety has to be built into the culture of a hospital, requiring the active participation and engagement from not only every hospital employee, but also from the CEO, environmental services staff, boards of trustees and hospital volunteers.

Bundles of help

Eliminating HACs also requires reliable implementation of a specific set of procedures, which we call “prevention bundles.” This means that when a medical procedure associated with a HAC is performed, every person involved in treating the patient follows a prescribed list of tasks at each and every time and in exactly the right way.

Over the last four years , more than 90 children’s hospitals from across North America have worked together to eliminate harm through the Children’s Hospitals’ Solutions for Patient Safety Network. Our experience shows that by putting competition aside, teaching and learning from each other, reliably implementing the prevention bundles and working with a sense of urgency, we truly can get to zero harm. And the sooner we get there, the more children’s lives we’ll save.