from event reporting to patient safety organization mark a. keroack, md, mph svp & chief medical...

From Event Reporting to Patient Safety Organization

Mark A. Keroack, MD, MPHSVP & Chief Medical Officer

AHRQ Annual Meeting 9/27/2010

Before the 2008 PSO RuleBefore 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

©2010 University HealthSystem Consortium 2

Adapting to the Final RuleAdapting 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



UHC PSN® Taxonomy

HERF and PIF:

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

Event Date/Time* Demographics*Harm***Interventions***

In both AHRQ CF and PSN

(fields extracted for NPSD)

Manager reviews, consultations and attached documents

Incorporating the Common FormatsIncorporating the Common Formats

PatientADRsAnesthesia/SedationBehavioralCare CoordinationComplications of careEmergency DeptEquipment/devicesFood/NutritionLaboratory TestMaternalMedication RelatedNeonatalRadiology/Imaging TestRespiratory CareSkin IntegritySupplySurgery/InvasiveProceduresTransfusion

Other Unsafe Conditions:Environmental IssuesEquipment SafetyMedication Equipment and CountsViolation of Infection ControlInappropriate Staff BehaviorSecurity IssuesRegulatory Reporting ProceduresStaff:AssaultExposure to Blood/Body FluidsExposure to Chemicals/DrugsInjuryOtherVisitor Events:AssaultCall to Medical Response TeamExposure to Blood/Body FluidsExposure to Chemicals/DrugsInappropriate Behavior InjuryOther

Remaining IssuesRemaining 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


The Real Value of PSOsThe 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 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 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


© 2010 University HealthSystem Consortium 9

0.00 0.00 0.000.41

0.660.93 1.10 1.11

1.36 1.411.79 1.81

2.54

3.20

0.430.87

1.141.76

2.63

5.80

0

2

4

6

8

1 2 3 4 5 6 7 8 9 10 11 12 13 14 A B C D E F

Blinded Unit ID

Rate Per 1000

Aggregate Data Analysis – 3Aggregate Data Analysis – 3

Mislabeled Specimen Rates Per 1000 Accessions

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

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

Critical Care Units ED Units

Mislabeled Specimens: “Campaign approach”

ConclusionsConclusions• 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


from event reporting to patient safety organization mark a. keroack, md, mph svp & chief medical...

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