From Event Reporting to Patient Safety Organization (Text Version)

On September 27, 2010, Mark Keroack made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (402 KB).  

---

Slide 1

From Event Reporting to Patient Safety Organization

Mark A. Keroack, MD, MPH
SVP & Chief Medical Officer

AHRQ Annual Meeting 9/27/2010

On top right of slide: UHC psn.

Slide 2

Before the 2008 PSO Rule

• UHC: a member owned alliance of 107 academic health centers (AHCs) and over 220 affiliates.
• Patient Safety Net: UHC's adverse event reporting and management system since 2002.
• Key lessons learned:
  • Standard taxonomy enables data mining.
  • Learning community fosters innovation and disseminates solutions.
  • Decentralized event management builds awareness and participation by unit managers.

Slide 3

Adapting to the Final Rule

• Component entity decision:
  • UHC Performance Improvement PSO
• Policies, procedures and training.
• Separate physical security for PSO reports.
• High reliability assessment for data security.
• Two types of customers (30 of 80 now in PSO).
• No current consensus among PSO members on what goes into PSO space and when.

Slide 4

Incorporating the Common Formats

UHC PSN® Taxonomy

Patient ADRs Anesthesia/Sedation Behavioral Care Coordination Complications of care Emergency Dept Equipment/devices Food/Nutrition Laboratory Test Maternal Medication Related Neonatal Radiology/Imaging Test Respiratory Care Skin Integrity Supply Surgery/Invasive Procedures Transfusion	Other Unsafe Conditions: Environmental Issues Equipment Safety Medication Equipment and Counts Violation of Infection Control Inappropriate Staff Behavior Security Issues Regulatory Reporting Procedures Staff: Assault Exposure to Blood/Body Fluids Exposure to Chemicals/Drugs Injury Other Visitor Events: Assault Call to Medical Response Team Exposure to Blood/Body Fluids Exposure to Chemicals/Drugs Inappropriate Behavior Injury Other	In both AHRQ CF and PSN (fields extracted for NPSD)
		HERF and PIF: Event Date/Time* Demographics* Harm*** Interventions*** Event Specific: Anesthesia** Blood** Equipment and Devices* Fall* Healthcare- Associated Infection*** Medication & Other Substances* Perinatal** Pressure Ulcer* Surgical and other invasive procedure**

*Direct Map
**Edit
***Adopt AHRQ

Manager reviews, consultations and attached documents

Slide 5

Remaining Issues

• Role of the PPC.
• Upcoming compliance review.
• Incomplete reports and selective participation.
• The larger federal agenda (CMS, CDC/NHSN).
• Upcoming challenges to the rule by plaintiffs.

Slide 6

The Real Value of PSOs

Leveraging federal protections in order to:

• Convene organizations with a shared interest in safety.
• Foster a climate of openness and disclosure.
• Develop insights from submitted data:
  • Aggregate event analysis.
  • Root cause analysis.
• Contributing to national learning (solutions as well as data).

Slide 7

Aggregate Data Analysis—1

Falls: Basic Surveillance Approach

• 27,201 falls selected for 2008.
• Peak numbers in 50-60 age group.
• Peak times 1-2 hours after meals.
• High rates of non-assessment in ED & Peds.
• Rethinking who is at risk and how to best deploy rounding resources.

Slide 8

Aggregate Data Analysis—2

Epidural-IV Confusion: "Tip of the Iceberg"

• 55 reports in literature 1968-2009.
• 31 event reports in PSN (most low or no harm).
• Both Epi to IV and IV to Epi.
• Hot spots in critical care and obstetrics.
• Lack of training, distractions, inexperienced staff listed as contributing factors.
• Labeling/alert approaches shared among sites, but definitive device solution still awaited.
• Analysis of low harm and near miss events builds awareness of issues.

Slide 9

Aggregate Data Analysis—3

Mislabeled Specimens: “Campaign approach”

Aggregate Performance (32 units in 12 sites over 1 month:
1.30 mislabelings / 1000 accessions (112 / 86,123)

Hospital Performance:
Mean: 1.45
SD: 1.36
Median: 1.13
Range: 0.00-5.80

Mislabeled Specimen Rates Per 1000 Accessions

Critical Care Units		ED Units
Blinded Unit ID	Rate Per 1000	Blinded Unit ID	Rate Per 1000
1	0.00	A	0.43
2	0.00	B	0.87
3	0.00	C	1.14
4	0.41	D	1.76
5	0.66	E	2.63
6	0.93	F	5.80
7	1.10
8	1.11
9	1.36
10	1.41
11	1.79
12	1.81
13	2.54
14	3.20

Slide 10

Conclusions

• The PSO Final Rule has imposed some (so far manageable) constraints on PSN.
• AHC involvement in PSOs is highly variable, and most remain uncertain about choosing one.
• Enthusiasm among newly formed PSOs is high.
• Continuing to demonstrate the value of PSOs by disseminating insights and solutions is critical for this young initiative.