Patient Safety Organization orientation for workforce

Center for patient safety pso PATIENT & PROVIDER SAFETY PROTECT Protect patient safety and quality work. PREVENT. Prevent adverse events and patient harm through supportive cultures. (Name of agency) has joined a Patient Safety Organization – the Center for Patient Safety located in Jefferson City, MO Why? To help us improve our patient safety and therefore patient outcomes. The PSO helps us (review slide) Protect ---- Learn ----- Prevent (from slide) LEARN Learn best practices and improvement opportunities.

How psos help improve patient SAFETY Aggregate data and reports from (name of agency) Providers can work together and learn from mistakes Non-punitive Providers receive protections How do PSOs improve safety? PSOs aggregate data from many providers to identify risk patterns of care and system failure Providers can work together in a confidential, protected space to share and learn how to prevent mistakes PSOs are not a regulatory body – there are no fines or slaps on the wrist. PSOs are here to help. Participating providers are assured that their safety work will not be used against them.

A federal law is AVAILABLE Patient Safety and Quality Improvement Act of 2005 (42 U.S. Code Part C - Patient Safety Improvement) Framework that encourages adverse event reporting Makes PSO reporting safe by providing federal protection Provides environment for safe and confidential sharing, learning and prevention What does that mean? There’s a federal law that encourages medical event and near miss reporting so we can learn from each other and prevent errors. The law provides protection for patient safety and quality information so it cannot be used against us in a lawsuit More importantly, it provides an opportunity to safety share with one another and learn from others’ errors – thus having a positive impact on our patient outcomes

PSO HOW PSOs WORK PSO COLLECTS DATA DATA IS ANALYZED LESSONS ARE SHARED Best Practices Alerts/Watches Resources/Toolkits Newsletters Webinars Conferences/Meetings PSO TYPES OF EVENTS COLLECTED: ADVERSE EVENTS NEAR MISSES UNSAFE CONDITIONS Air Medical Service EMS Fire Based EMS Hospital Based On the right, PSOs collect events such as medical errors or near misses and they are entered into an on-line database Then in the middle of this graph the PSO then analyzes the data and reports back to the PSO participants via best practices, lessons learned, Safety Watches. Safety Alerts, patient safety resources, newsletters, webinars and conferences for its members On the right is the list of types of agencies and bases that can get the information to improve patient safety Private Ambulance Svc PUM

EMPLOYEE RESPONSIBILITIES Report medical errors, near misses and unsafe conditions per (name of agency’s) policy Keep information confidential – use only within (name of agency) to improve patient safety Commit to improving patient safety to ultimately improve patient care All employees are expected to report near misses, medical errors and unsafe conditions per agency’s policy Patient safety information is much like HIPPA – the federal law protects the information and it can be used only within the agency to improve patient safety. There are civil fines for breaches. Most important – each and every leader and crew member commits to do everything possible to improve patient safety – as it ultimately means we provide better patient care and have better outcomes.

What to report Medical Event (Incident) – A patient safety event that reached the patient, whether or not the patient was harmed Near Miss: A patient safety event that did not reach the patient Unsafe Condition: Any circumstance that increases the probability of a patient safety event

What to report - Examples Airway Management Esophageal Intubations Dislodged devices Difficult airways Cricothyrotomy or other high risk airway events   Ambulance Crashes Crash or almost crashes - What factors played a role in the crash?  Dangerous road, fatigue, distractions

What to report - examples Device/Medical Supply Stretcher failures - Battery failed or other mechanical failure Stretcher tips or collapses IV pumps, cardiac monitor or ventilator failure Incorrect equipment or medication ordered or stocked on ambulance Lost or missing equipment Medication/Other Substance Medication mistakes - violation of the 5 rights for med administration  Exposing a patient to known sensitivity or allergy-latex Expired medications Incorrect calculations (i.e. for bariatrics or peds)

What to report - examples  Other Protocols not followed Behavioral Health Harm to crew or patient - violence to EMS crew, patient jumping from ambulance Extended transports or resource utilization,  extended wait times Bariatric Patients Harm to patient or crew during handling Dispatch Error Sent to the wrong address or given information that places patient or crew in harm’s way. Vehicle Incidents Lost keys - can’t start the ambulance and respond to a call

Why report? Decreased fear in reporting medical errors, near misses and unsafe conditions Opportunity to learn from others within (name of agency) Opportunity to learn from other agencies across the nation Ultimately provide safer care, resulting in improved patient outcomes

QUESTIONS OR ASSISTANCE (Enter Agency PSO contact information): Center for Patient Safety 573-636-1014 www.emsforward.org www.centerforpatientsafety.org/emsforward Insert agency’s contact person Contact Center for Patient Safety for assistance