Patient Safety Data Standards Committee

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Patient Safety Data Standards Committee

• Nancy Ridley, MS
• Assistant Commissioner
• Massachusetts Department of Public Health
• April 1, 2003

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Massachusetts 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

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Massachusetts 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

4
Massachusetts 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

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Massachusetts 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

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Massachusetts 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

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Massachusetts 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

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Massachusetts 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

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Massachusetts 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

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Massachusetts 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

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Massachusetts 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?

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Massachusetts 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

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Massachusetts 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

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Standard 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

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Addressing 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 ?