Florida Patient Safety Corporation

1
Where Are We? The 2005 Florida legislature and
Governors initiatives to fund a Near Miss
reporting system was authorized by the
Legislature through the Florida Patient Safety
Corporation. As a result, a contract was awarded
to The University of Miami/Jackson Memorial
Hospital Center for Patient Safety (UM-CPS) in
conjunction with consulting partners Marsh (CS
STARS) and CRG Medical (AIMS). Their objective is
delivery of software and consulting services to
the Florida Patient Safety Corporation for
creation of a near miss reporting and analysis
system. This will lead to (a series of)
recommendations for changes in healthcare
practices and procedures (resulting in a) to
reduce the frequency and severity of medical
error in Florida. Mishaps due to medical
management are blamed for 44,000 to 98,000 U.S.
deaths a year, perhaps more. Patient safety
adverse events rank as the eighth leading cause
of death in this country. The lethal nature of
patient safety problems and the disparity between
healthcare and other industries in handling
safety issues was highlighted by the 1999
Institute of Medicine report (To Err Is Human) -
leading to a ground swell of demands to develop a
strategic approach to understanding error, safety
reporting, and building a culture conducive to
improving patient safety. This year, President
Bush signed Senate Bill 544 into law establishing
criteria for certification of Patient Safety
Organizations (PSO). Floridians should be able
to count on receiving health care that is safe.
To achieve this, a better healthcare delivery
system is needed - a system that prevents errors
and learns from them when they occur. This
requires a commitment by all stakeholders to a
culture of safety, improved information systems
and a commitment to organizational learning.
Through the FPSC and its grants, the state of
Florida is now pursuing research to improve
patient safety. This project will concentrate
on near misses. The Institute of Medicine (IOM)
concluded that the overwhelming majority of
adverse events are preventable and result not
from human error, but from system weaknesses. We
need to better understand why near misses/close
calls occur.
What Do We Want To Achieve? We hope to create a
culture in which doctors, nurses, and other
healthcare providers feel comfortable enough to
voluntarily report on near misses. Although we
cannot change the human condition, we can change
the conditions in which a human works.
- James
Reason In order to Fix the System, we need to
know about errors - even the ones that dont
cause adverse outcomes (near misses). In this
pilot study we want to learn from the success of
the aviation error reporting system and its
components. According to the Aviation Safety
Reporting System (ASRS) there must be the
following elements for success What Can
We Expect From This Program?

• Why Look at Near Miss?
• Studies suggest that there are approximately 100
  (range 3 300) near misses for every adverse
  event resulting in patient harm. Data also
  indicates that there are many predisposing unsafe
  conditions for every near miss. The figure below
  illustrates the relationship between adverse
  events, near misses, and unsafe conditions.
• By identifying near misses and analyzing their
  causation it affords healthcare professionals
  additional opportunities to avoid the adverse
  event which may lead to Medical Legal claims and
  the erosion of public trust.
• Florida is already credited with having one of
  the leading adverse event reporting systems in
  the US (Kohn, 1999). The code-15 reporting system
  collects reports from the majority of health care
  facilities in Florida about severe patient harm
  events. Near misses represent a totally different
  set of events, however, and are not currently
  being reported. This pilot project of the FPSC
  will allow us all to benefit from each others
  experiences in regards to near misses.
• Evaluating Medical Errors
• It is our hope that through this study we will
  be able to concentrate on the Systems Approach,
  thus focusing on the policies, procedures and
  system failures that healthcare professionals and
  administrators must deal with on a day-to- day
  basis.
• - David Birnbach, MD - Director
• Center for Patient Safety, U of M - JHS
• System Approach Focuses On The System

Florida Patient Safety Corporation Initiates the
State of Floridas Near Miss Reporting System

• Anonymity
• Non-discoverable
• Non-punitive
• Guarantee of immunity for those who voluntarily
  report errors that they have made

The Florida Patient Safety Corporation is
engaged in a critical mission - building a
foundation for safer patient care and fewer
medical errors. Establishing a Near Miss
Reporting system is an important component of
this foundation which is why I recommended
funding for the program in the 2005-06 budget.
The Corporation's mission requires teamwork.
Providers, patients, and the public must work
together to enhance systems of care. I applaud
the healthcare professionals and institutions who
embrace this initiative and demonstrate their
leadership and commitment to continuous quality
improvement. - Governor Jeb Bush

• Improve patient safety in Florida
• Decrease number of bad outcomes
• Decrease the number of malpractice claims over
  time
• Learn from patient advisories, timely
  publications when discoveries are made, lectures
  and support for Patient Safety Organizations in
  Florida
• Ultimately increase the number of participating
  hospitals to cover the entire State

• The System Approach is a structural or hard fix
• Errors are caused by system failures
• Our systems are generally flawed, but excellent
  workers allow them to function
• To improve safety, focus on system changes, not
  human changes

• "The Florida Patient Safety Corporation is proud
  to be one of the few groups nationwide studying
  "near miss" reporting and its effect on patient
  safety. As our study moves forward, data will be
  collected from participating institutions, purged
  of all identifiers and analyzed for trends.
  Feedback will be provided, through a variety of
  methods, to Floridas healthcare community and
  can be used by each institution to reduce future
  near miss or adverse incidents. I encourage you
  to become part of this cutting edge effort by
  volunteering to be one of the charter members of
  this study.
• Thomas M. Rozek
• Chairman, FPSC
• President, Miami Childrens Hospital

• 35 of the hospitals have made changes in their
  operating procedures due to this new data.
• Immediate Patient Safety Advisories are issued by
  e-mail mail when data suggests the potential of
  statewide patient harm.

Florida Patient Safety Corporation 2722 Waterford
Glen Court Tallahassee, Florida 32312 (850)
893-8936 www.floridapatientsafetycorp.com
2
Florida Patient Safety Corporation Near Miss
Report
Summary of FPSC Voluntary Near - Miss Reporting
System
The FPSC Asks You To Apply For Participation In
This Voluntary Program

• An application is available online at the Florida
  Hospital Association website, www.FHA.org. Fill
  out and e-mail to Dr. David Birnbach at
  dbirnbach_at_miami.edu or mail to address provided.
• Initial participation will be based on size,
  specialty, structure and region. We want a true
  cross - section of our community including 20
  hospitals, two birthing centers and two
  ambulatory care centers.
• Selected volunteers will participate in the
  design and structure of the reporting system.
  The timeline currently calls for selection of 4-6
  institutions by December 1, 2005 for testing.
  Our goal is to have a live program in April 2006.
• With your input we will further develop a report
  form that will be effective and simple to
  complete. Here is a first DRAFT.