1. House Officer Association Organization to represent the House Officers Representatives from each program elected to membership Members bring issues forward to Hospital Administration Meetings on the 1 st Tuesday of every other month (next one 10/6/09, 6 pm, KPV 5001) Leadership – Corinne Cohen, MD, Family Medicine, Co-President, cohenc@ohsu.edu cohenc@ohsu.edu – Melissa Weimer, DO, Internal Medicine, Co-President, weimerm@ohsu.edu weimerm@ohsu.edu – Owen Ratigan, MD, Internal Medicine, Vice President, ratigano@ohsu.edu ratigano@ohsu.edu GME Staff contact – Clea English, MPH, Associate Director, GME, englishc@ohsu.edu, 4-1053 englishc@ohsu.edu General E-mail: SOMHOA@ohsu.eduSOMHOA@ohsu.edu

2. Retirement Benefit All residents are guaranteed 1.5% pre-tax annual retirement benefit As of 2006-2007, Another 1.5% is available if residents fulfill annual service excellence goal Track Record: – 2006-2007: goal achieved – 2007-2008: goal not achieved – 2008-2009: goal achieved – 2009-2010: ????

3. 2009-2010 Goals (Oct – May) 1)Resident Safety Event Reporting – Historically, 0.9% of reported events are by residents – Goal in 08-09  5% – Projected to be 240 resident reported events per year or about 20 per month – 2009-2010 goal → 6% resident involvement in QI projects related to reports is encouraged but not mandatory to meet goal

4. 2009-2010 Goals (Oct – May) 2) Seasonal flu vaccination (not H1N1) - 90% goal for all patients admitted with pneumonia (Joint Commission requirement) -60% goal for “at risk populations” -Ambulatory and Inpatient encounters in denominator – Internal Medicine, Family Medicine, Obstetrics and Gynecology - Completion of order to give or documentation of exclusion meets criteria - Pediatric encounters are evaluated on first order given only - Periods of vaccine shortage excluded

5. 08-09 PSN Reporting by Service Clinical ServiceTotal Reports# ResidentsReporting % Medicine649369% Surgery w/ Peds Surgery 8277106% Pediatrics6043139% Ob-Gyn5925236% Family Medicine4538118% ED93030% Otolaryngology51631% Other4 Anesthesia4356% Psychiatry32910%

6. Resident Education Patient Safety Net (PSN) What is it? What do we do with the information? System issues identification How you can make a difference Benchmarking Advantages of reporting

7. Patient Safety Net Electronic incident reporting system Instituted in 2006 Average 400 monthly incident reports Highest # of PSN reports: 1. Medication Errors: Top 3: Vancomycin, Hydromorphone, Insulin 2. Errors related to Procedure Treatment & Test

9. What Should I Report? Anything you think is unsafe Any event you have observed that is not meeting the standard of care Examples: 1. Missed pathology report 2.Pneumothorax 3.Retained Foreign Body 4.Lacerations 5.Medication Errors 6.VTE in the absence of prophylaxis 7.Near misses 9. Untoward events related to incomplete sign-out

10. How does this help me? Protected Peer review information- not discoverable. Able to trigger your memory at a later date. Good documentation in the chart of an adverse event will also assist you. Documenting in the chart → just the facts of the event, no assumptions as to cause and no blame. Never document that an incident report was filed. New dot phrase for disclosure:.disclosureofadverseevent

11. Access to PSN You can access the PSN reporting tool at the GME website listed under House Officer Retirement Benefit http://www.ohsu.edu/som/gme/ OR Access @ Health Care System web page on OZONE http://ozone.ohsu.edu/healthsystem/ dept/risk/UHC-PSN/

13. How we can help We will report the data at your HOA meetings. We hope to make safety changes based upon your input. Clinical Risk pager 17049 available 24/7