Patient Safety Data Standards Committee - PowerPoint PPT Presentation

1 / 15
About This Presentation
Title:

Patient Safety Data Standards Committee

Description:

Massachusetts Reporting Demonstration Project: Aim 1 ... Massachusetts Reporting Demonstration Project: Aim 1. Clarify List of Reportable Events ... – PowerPoint PPT presentation

Number of Views:66
Avg rating:3.0/5.0
Slides: 16
Provided by: prop228
Category:

less

Transcript and Presenter's Notes

Title: Patient Safety Data Standards Committee


1
Patient Safety Data Standards Committee
  • Nancy Ridley, MS
  • Assistant Commissioner
  • Massachusetts Department of Public Health
  • April 1, 2003

2
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

3
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

5
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

6
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

7
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

8
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

9
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

10
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

11
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?

12
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

13
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

14
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

15
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 ?
Write a Comment
User Comments (0)
About PowerShow.com