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From Event Reporting to Patient Safety Organization (Text Version)

Slide presentation from the AHRQ 2010 conference.

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

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

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

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

Incorporating the Common Formats

UHC PSN® Taxonomy

Care Coordination
Complications of care
Emergency Dept
Laboratory Test
Medication Related
Radiology/Imaging Test
Respiratory Care
Skin Integrity
Surgery/Invasive Procedures

Other Unsafe Conditions:
Environmental Issues
Equipment Safety
Medication Equipment and Counts
Violation of Infection Control
Inappropriate Staff Behavior
Security Issues
Regulatory Reporting Procedures

Exposure to Blood/Body Fluids
Exposure to Chemicals/Drugs

Visitor Events:
Call to Medical Response Team
Exposure to Blood/Body Fluids
Exposure to Chemicals/Drugs
Inappropriate Behavior Injury

In both AHRQ CF and PSN (fields extracted for NPSD)


Event Date/Time*

Event Specific:
Equipment and Devices*
Healthcare- Associated Infection***
Medication & Other Substances*
Pressure Ulcer*
Surgical and other invasive procedure**

*Direct Map
***Adopt AHRQ

Manager reviews, consultations and attached documents

Slide 5

Remaining Issues

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

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

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

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

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



  • 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.
Current as of December 2010
Internet Citation: From Event Reporting to Patient Safety Organization (Text Version). December 2010. Agency for Healthcare Research and Quality, Rockville, MD.


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