Patient safety registry learnings Lori Skinner, DNP, RN Quality & Patient Safety Clinical Specialist

Adverse Health Events Year 13

Overview Total Events & Total # of Deaths Peer Review Protected Information

Overview of year 13 Pressure Ulcers Bio. Specimen Falls

Overview of event location 95 76 50 16 13

Surgical: Wrong body part overview Peer Review Protected Information

Surgical: Wrong body part

Surgical: Wrong procedure overview Peer Review Protected Information

Surgical: Wrong procedure

Surgical: Retained foreign object overview Peer Review Protected Information

Biological specimen Peer Review Protected Information

Pressure ulcer overview Peer Review Protected Information

Pressure ulcer overview Peer Review Protected Information Device Related Year 10 24 (25%) Year 11 42 (39%) Year 12 39 (38%) Year 13 53 (41%)

Falls overview Peer Review Protected Information

Medication error overview Peer Review Protected Information

Failure to communicate test results

Attempted suicide overview Peer Review Protected Information

Physical & sexual assault overview Peer Review Protected Information

Root cause category trends

What do we do with this data? Creation of new patient safety registry Recommendations and guidance Safety alerts Good catch for patient safety award MHA quality and patient safety committees Regional safe table discussions Plan for the future

The new patient safety registry (PSR)

PSR changes Organizations now have the ability to identify more than one root cause Interactive data dashboards

Recommendations and guidance 2016 Additions: Biological specimen and courier services Medication errors related to clinical judgement Clarification on maternal hemorrhage as a serious injury Research continues to better understand sexual assault and workplace violence

Safety alerts

Good catch for patient safety The MHA Good Catch for Patient Safety award is presented to Minnesota hospital staff who demonstrate their commitment to keeping patients safe by "speaking up" to prevent potential harm to a patient. MHA encourages individual and team nominations, or nominations for system or organizational process and safety improvements that were made to prevent near misses and good catches from reaching patients. It is because of actions taken every day by dedicated professionals like the Good Catch Award honorees that Minnesota hospitals continue to be front-runners in patient safety. Since its inception there have been a total of 29 Good Catch Award Winners

MHAs quality and patient safety infrastructure MHA has several quality and patient safety committees that are comprised of experts from around the state that assist us with understanding current best practices. Those circled in red indicate that the committee is associated with an AHE. Each AHE data point we discussed early has impacted the work plan of our committees. The Registry Advisory Committee is the committee that first examines the data and recommends that The surgical committee has seen a trend in data indicating that the time out is not being done consistently for all procedures. As a result the surgical committee is spending 2017 improving the time out process and providing organizations with clear expectations. Medication safety is working on developing a medication reconciliation process, perinatal is focused on maternal early warning signs, falls is working on bathroom safety as these continue to be a challenging area and pressure ulcer will focus on device related injuries.

Registry advisory committee charter

Registry advisory committee 2017 work plan Priorities: Strategies: Enhance analysis and actionable information from patient safety registry   Triage emerging trends based upon data to expert QPS committee for intervention/action Enhance Good Catch Award participation by hospitals and health systems across MN Review current and past good catch nominations Strengthen data reports and data sharing

Regional safe table discussions

Where is the registry going Updating resources based on current evidence based practice Exploring the RCA² model Building reports to dive deeper into corrective action plans and good catch nominations Continue to refine best practice questions

Questions