Title: Patient Safety Data Standards Committee
1Patient Safety Data Standards Committee
- Nancy Ridley, MS
- Assistant Commissioner
- Massachusetts Department of Public Health
- April 1, 2003
2Massachusetts Reporting Demonstration Project
Aim 1
- Clarify list of reportable events required by
statute and regulation - Update reporting form
- Examine possibility of web-based system
- Establish system for analyzing contributing
factors - Establish corrective actions tool
3Massachusetts Reporting Demonstration Project
Aim 1
- Clarify List of Reportable Events
- Specify list of serious incidents that must be
reported under 105 CMR 130.331, Using National
Quality Forum list as a starting point
4Massachusetts Reporting Demonstration Project
Aim 1
- Serious Incidents will continue to be
requirement under regulations - Examples
- Poisonings occurring in a facility
- Disease outbreaks within a facility
- Equipment malfunction
- Medication error
5Massachusetts Reporting Demonstration Project
Aim 1
- New Reporting Form Incident Description
- Event
- Attempt to specify coding categories.
- Example Include category for treatments done
to wrong patient as well as procedures
6Massachusetts Reporting Demonstration Project
Aim 1
- New Reporting Form Incident Description
- Severity of Injury (replacing harm type)
- No Injury
- Death
- Severity (physical) and duration
- Death, unanticipated loss of 1 or more ADL, new
chronic or acute illness (including pain), change
in existing condition - Severity (mental) and duration
- Death, Loss of 1 or more cognitive abilities,
psychotic symptoms or delirium, emotional distress
7Massachusetts Reporting Demonstration Project
Aim 1
- New Reporting Form Incident Description
- Severity of Injury (replacing harm type)
- Expected Duration of Harm
- Less than seven days
- Seven days to three months
- Three to six months
- More than six months
8Massachusetts Reporting Demonstration Project
Aim 1
- New Reporting Form Incident Description
- Type of Injury (still being modified)
- Surgical events
- Product or device events
- Care management events
- Environmental events
- Procedure-related events
- Quality of life/regulatory violations
- Other serious events
9Massachusetts Reporting Demonstration Project
Aim 1
- Web-based System
- For receiving both incident reports and consumer
complaints - Increases the importance of common language,
recognition of terms by providers filing reports
and patients filing complaints
10Massachusetts Reporting Demonstration Project
Aim 1
- Contributing Factors Database
- Reporter should be able to code certain events
and this should lead to determination of which
systems broke down - Then system will pop out list of contributing
factors according to the answers given - Considering referring to this category as
associated factors
11Massachusetts Reporting Demonstration Project
Aim 1
- Corrective Action Framework (based on Vincent,
BMJ, 2000) - Transitions, work environment, team
communication, etc - Should this be confidential? (fear of litigation)
- Problem of subjectivity in some of the questions
- Ex At the time of the incident, was there a
mismatch between workload and staffing levels?
12Massachusetts Reporting Demonstration Project
Aim 1
- Restructuring Data Storage System
- Analysis and report generation
- Currently piloting a data abstraction tool
- Information to hospitals through annual
summaries, and ability to access their own report
information - Can assist in Quality Improvement measures
13Massachusetts Reporting Demonstration Project
Aim 1
- Restructuring Data Storage System
- Analysis and report generation
- Annual Summaries to Public
- How do we determine what information the public
really wants? - Risk of wasting time and resources setting up
system that public may not access - Often public is responding to events they hear
about in the media
14Standard Approaches for Investigations?
- Currently, Mass DPH staff triage reports for
on-site vs. off-site investigations - Is it possible to standardize this? Can one size
fit all? - Ever present issue lack of resources
15Addressing Near Misses
- Massachusetts system does not currently collect
such data, nor is demonstration project looking
at this. - How can this data be collected without violating
providers confidentiality ?