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).
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.
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.
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.
Incorporating the Common Formats
UHC PSN® Taxonomy
Complications of care
Other Unsafe Conditions:
|In both AHRQ CF and PSN (fields extracted for NPSD)|
HERF and PIF:
Manager reviews, consultations and attached documents
- 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.
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).
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.
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.
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)
Mislabeled Specimen Rates Per 1000 Accessions
|Critical Care Units||ED Units|
|Blinded Unit ID||Rate Per 1000||Blinded Unit ID||Rate Per 1000|
- 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.