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

2. Adverse Health Events Year 13

3. Overview Total Events & Total # of Deaths
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4. Overview of year 13
Pressure Ulcers
Bio. Specimen
Falls

5. Overview of event location95 76 50 16 13

6. Surgical: Wrong body part overview
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7. Surgical: Wrong body part

8. Surgical: Wrong procedure overview
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9. Surgical: Wrong procedure

10. Surgical: Retained foreign object overview
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11. Biological specimen
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12. Pressure ulcer overview
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13. Pressure ulcer overview
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Device Related
Year 10
24 (25%)
Year 11
42 (39%)
Year 12
39 (38%)
Year 13
53 (41%)

14. Falls overview
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15. Medication error overview
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16. Failure to communicate test results

17. Attempted suicide overview
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18. Physical & sexual assault overview
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19. Root cause category trends

20. 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

21. The new patient safety registry (PSR)

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

23. 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

24. Safety alerts

25. 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

26. 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.

27. Registry advisory committee charter

28. 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

29. Regional safe table discussions

30. 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

31. Questions