RefresherRefresherResearch Coordinators MtgResearch Coordinators Mtg

02/27/12

P S NPatient Safety Net

1

2

3

4

Introduction

Use of Patient Safety Net at the SCCA

Patient Safety Net Access

Navigating through PSN

Table of ContentsTable of Contents

4321

Use

of P

atien

t Saf

ety

Net What is Patient Safety Net® (PSN)?What is Patient Safety Net® (PSN)?

PSN is an anonymous online reporting system used at the Seattle Cancer Care Alliance.

PSN is used to track events that occur at the SCCA such as:– Unsafe Conditions: Environmental factors or work processes that have a Environmental factors or work processes that have a

potential to harm a patient/visitor*.potential to harm a patient/visitor*.– Near Misses: Events that do not reach the patient/visitor but had the do not reach the patient/visitor but had the

potential to harm or inconvenience the patient/visitor if it had not been potential to harm or inconvenience the patient/visitor if it had not been corrected before reaching the patient/visitor.corrected before reaching the patient/visitor.

– Events that Reach the Patient/Visitor: Events that reach the patient/visitor reach the patient/visitor causing harm or inconvenience.causing harm or inconvenience.

*Visitor refers to a patient’s family member or caregiver.

Please Note! We do not use PSN to track events that reach staff, if you slip, trip, or have a needle stick, please report those using an Accident Illness Report form.

4321

Use

of P

atien

t Saf

ety

Net The Role of PSN at the SCCAThe Role of PSN at the SCCA

Learning from Events, Near Misses, and Unsafe Conditions is key in monitoring and improving our process for safety and efficiency.

o A system flaw or gap can go undetected without your PSN report.

o When an error occurs, the review often uncovers system vulnerabilities that could be improved upon.

o Learning from PSN events help the SCCA to build better systems to promote patient safety and support your work.

o The ultimate goal is to protect patients from harm.

4321

Use

of P

atien

t Saf

ety

Net Some Examples of Event Reports:

– Medication Events• Medication Delays

– Laboratory or Specimen Events• Not Completed• Results Delayed

– Patient/Visitor Falls– Communication/Care Coordination Problems

• Scheduling Issues• Unclear Orders

– Equipment, Supply, or Device events– Environmental Hazard

4321

Patie

nt S

afet

y N

et A

cces

s

• All staff have the ability to enter a PSN.All staff have the ability to enter a PSN.• Access to PSN is granted by using your UW AMC/IRIS Access to PSN is granted by using your UW AMC/IRIS

Logon information (also known as your Logon information (also known as your Orca/Mindscape password).Orca/Mindscape password).

• If you do not have an AMC account, work with your If you do not have an AMC account, work with your manager to fill out the PSN access request form manager to fill out the PSN access request form found at O:\Computer Applications Access forms.found at O:\Computer Applications Access forms.

• PSN is accessed via the link: PSN is accessed via the link: • https://psn.medical.washington.edu/login.aspx?

ReturnUrl=%2fdefault.aspx

PSN Account AccessPSN Account Access

4321

Patie

nt S

afet

y N

et N

avig

ation

Operation of PSN

4321

Patie

nt S

afet

y N

et N

avig

ation Entering and Event

• PSN Icon is located on all SCCA Clinic Desktops and identified by this icon

• Research Staff not in the clinic access via the following Link (saved to favorites or manually as a link on desk top)

• https://psn.medical.washington.edu/login.aspx?ReturnUrl=%2fdefault.aspx

4321

Patie

nt S

afet

y N

et N

avig

ation Concepts to Remember When

Entering an Event• The intent of PSN is to track system issues in patient

care, not to finger point. • When entering an event, be as objective as possible.• PSN events can be reported anonymously. If you do

not document your name at the end of the report, you will not be identified as the reporter.

• Enter “Research Patient” as the first two words in the event description.

4321

Patie

nt S

afet

y N

et N

avig

ation Navigating Through PSN

https://psn.medical.washington.edu/login.aspx?ReturnUrl=%2fdefault.aspx

4321

Patie

nt S

afet

y N

et N

avig

ation Event or Near Miss

Occurs and Event Entered by Front

Line Reporter

Immediate Email notification of new event is triggered

to:

The Life of a PSN Event

Online Event Entry

Department Manager where event occurred

Ancillary Manager if specific event type (ie. Falls, Transfusion

events)

Pharmacy Manager (if

Medication Error)

Quality Manager (All Event Types)

Risk Manager (High Harm

Scores)

Lab Quality Manager (If Lab

Event)

Sends consultation to additional managers for

feedback if needed

Manager Reviews event, documents any follow up, and

submits.

Reviews for harm severity

and adjust harm score as

needed Quality Manager

Does final review of event and all

manager reviews, submits event to

UHC.

Event Review

CCP Quality Manager

(Product Related Events)

NOTE: “Managers” can be Physicians, Pharmacists, Nurse

Managers, Lab Managers,

Conducts Root Cause Analysis

as Needed

4321

Patie

nt S

afet

y N

et N

avig

ation

All Submitted Events Available for review for each managers

respective area.

Data Reports Compiled by Quality for distribution/review throughout the clinic

DashboardsMonthly

Departmental Specific Reports

Standing Committee Reviews of specific event types (ie. Med

Errors, specimen labelling)

Ad Hoc Reports by manager request, for

example:

Event Reports

Event “Type” Specific Reports (ie. Falls)

Falls

Chemo Spills

Apheresis

GenOnc

Apheresis

Transfusion Services

Patient Safety Council

Medication Safety

Transfusion Cmt

Environment of Care

GenOnc

HSCT

Imaging

WomCen Imaging

Research

Infusion

Alliance Lab

Pharmacy

Proc Suite/ IR

Reqing Crew

Womens Center

National Patient Safety Goals

Contrast Reactions

Blood Irradiation

Mislabeled Specimen

Adverse Drug Reactions

Laboratory Quality

CCP Quality

Infusion

Inpatient Ops

Medical Imaging

Medical Staff

Pharmacy

Procedure Suite and IR

Lab QI

Radiation Oncology

HSCT

WomCen

Need Help?

For any questions regarding Patient Safety Net, contact:

Maya LuzziPatient Safety Net Onsite Administratormluzzi@seattlecca.org288-2236