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                  JL N eptune    Kathy Kenyon, JD
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• Bt r el, Bt r a , Bt r a e hog Qul Ipoe et
   e e H ah e e C r e e Vl t uh a ymrvmn
    t     t  t    e t     u r      it
 – Fr e t m s n f e ea mn o H ah n H mn e ics
   ut rh is o t D pr et f el ad u a Sr e
     h e io      h    t        t         v
 – H h h por s c its n is e o cne
    igl t rg m, at ie, ad s s focr
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• Su I oa n n H h h Eclne
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 – M ta , inpeaded
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• C m uitbil g D vl mn o eoy e
   o mny ud – ee p et fcs t
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• S u t pivt sc r vs et
  t le ra et inet n
   im a    e o      m
W you o R p r g de e vn ?
   h f s n eot A vr Eet
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• N ational Q uality Strategy # 1 Priority –

“M k gc r s f rb rd c gt eh r c u e int e
  a in ae ae y e u in h am a sd h
 d liv r o c r.”
  e e y f ae

• H aha ra d r rcn u t acuto a
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     t e le r        in        r
  snicn a on o hr ad et in h A e a
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                m       h e     ic
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 – 1 3 opa a n hv avr eet( E)t tec ptn
    in hsitizt s ae de e vn A s h r h a t
            l io       s   s    a a    ie s
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     e o o ko aot E in mu trst g
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M shah a ogn a n
    ot el cr r izt s
        t e a io
   clcA s u nte wl
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• Et a s a , bt r ett yon t t 4 o
   s t vr u ae n s d f d h 1% f
    im e y       c  u u     a
  inidn t t a e Md a bnfia s
    c et h hr d eicr ee r in
       s a m        e   ic ie
  hsits e r ot .
   opa wr e r d
       l e p e
 – D sit t f tht eicr cnitn o pr iptn
    epe h a t Md a odios fa ic a
          e c a     e          t io
   r ue c eteotg m shah a
   e ir inidn r r in ot el cr
    q          p in       t e
   ogn a n ( log nt a bloy r te)
    r izt sahuh o in mu trpa ics
     a io    t           a    c .
A R Ptn Sfy gn a n ( S )
   H Q’s a ta tOr izt sPOs
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Cet b t Ptn Sfy a ymrvmn A t f
 r e yh a t a tQul Ipoe et co
  ad     e ie  e     it
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 – Al hah a poidrt clcad nle a whu
    lw el cr rv e o oetn aaz dt it t
    o     t e    s   l     y  a o
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 – Mspoeth pivc o ptn ad eotg
    ut rt t ray fa t n r r
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   ogn a n.
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• C r nyhr a 7 POsis d it A R
   ur t t e r 5 S le wh H Q.
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 – Sosrinl e opaa oia n, hah y e s
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           u        l s io    t sm
   cl oa n o hah y e sinl in aae ic eicl
    oa r ios fel s t ( c d g cdm md a
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C m o Fr a ad eotg
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 – A R PO Pivc Poetn et hs C s n r oe
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• Poidrmy l ue F t sn r ott s t aec s
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D s ip n A p hu . . .
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• Ealpoidrt imote vn E RP Rad t r
   nb rv e o p rreat M , H , n oh
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   ul el o hah vr h og izt s c d g
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  s t o f e lrg m o ac din o cr y g
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    a     da      a       e        t in
  bd s
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• B p t r - got;
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• Lvr e n et d w I s na s n sr e
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    c d g u nt e o r sotD e , wb
     u         im d     a        c
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   e ics ot tTa itn o C r C /C ) n
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• Iomt n n S ad o m n omtis
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• T e o m n omtv .2 aaalo te S
   h C m o Fr a 1 is vil e n h PO
               s        b
Pivc Poet n et wbit a
 r ay rt io C ne ese t
        c      r
hts/w .po p.og e/ tns e
 t :/ w spc r/ b a t f y
  p w         w p ie a t
J g g re
             u in Cit ia
              d      r
1.   Ef civ n s o t esse inf c ain p t n s f t
      fe t e e s f h y t m a ilit t g aie t aey
     e e t rp rin in lu in it c m lia c w hA R ’s
      v n e ot g c d g s o p n e it H Q
     C m o F r as
      o m n om t
2.   U a ilit a dd s nf o t esa d o t o a
       s b y n e ig rm h t n p in f ll
     sa e o es
      t k h ld r
3.   A ilit t ine r t w he crn h a hrc r sa doh r
      b y o t gae it le t o ic e lt e od n t e
     H d t suc s
       IT aa o re
4.   Ce t it a din o aio
      raiv y n n v t n
5.   L v r g N H sa d r sin lu in t a s ot c ne t
      e ea e w IN t n ad c d g r n p r, o t n,
     a dv c b laie
      n oa u r s
T ee
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• Sb is n eio bg sJ e21
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• Sb is n e d ns uut 121
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• W nranucd Sp me 21
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Reporting Patient Safety Events Challenge Webinar

  • 1. R p r g a n Sfy vn eot Pt t a tEet in ie e s C a ne hl g l e W ebinar Presentation M na, Jy 621 ody u 1, 02 l
  • 2. On o a’s a tdy cl l : A dam JL N eptune Kathy Kenyon, JD W ong Sn r ic eio V e Mngmn ad aae etn Sn r o y nlt eio P l A as ic y Peidn r et s Por A as rg m nlt a y H H S/O N C H ealth 2.0 H H S/O N C
  • 3. A ed f T dy Me g gnao o a’s et r in  ON ad h I et g I oa n i2 C n ten s inn vt ( ) v in n io Porm rga  R p r g a n Sf y vns hlne eot Pt t a t EetC aeg in ie e l  Q& A o th C aeg A b u te hlne l
  • 4. ON ad C n i2
  • 5. i2 ol Gas • Bt r el, Bt r a , Bt r a e hog Qul Ipoe et e e H ah e e C r e e Vl t uh a ymrvmn t t t e t u r it – Fr e t m s n f e ea mn o H ah n H mn e ics ut rh is o t D pr et f el ad u a Sr e h e io h t t v – H h h por s c its n is e o cne igl t rg m, at ie, ad s s focr ig a iv u n • Su I oa n n H h h Eclne prn vt ad igl t xeec n io ig l – M ta , inpeaded oivt sir n l e , a • C m uitbil g D vl mn o eoy e o mny ud – ee p et fcs t in o sm • S u t pivt sc r vs et t le ra et inet n im a e o m
  • 6. W you o R p r g de e vn ? h f s n eot A vr Eet c in s s • N ational Q uality Strategy # 1 Priority – “M k gc r s f rb rd c gt eh r c u e int e a in ae ae y e u in h am a sd h d liv r o c r.” e e y f ae • H aha ra d r rcn u t acuto a elcr e t e osot e o con f t e le r in r snicn a on o hr ad et in h A e a igifatm ut fa n da t mr n m h e ic hah a s t ec ya el cr y e ah er t e sm . – 1 3 opa a n hv avr eet( E)t tec ptn in hsitizt s ae de e vn A s h r h a t l io s s a a ie s – W d ntnw b u A s a bloy e ins e o o ko aot E in mu trst g a t
  • 7. M shah a ogn a n ot el cr r izt s t e a io clcA s u nte wl oet E, bt o vr e l y l • Et a s a , bt r ett yon t t 4 o s t vr u ae n s d f d h 1% f im e y c u u a inidn t t a e Md a bnfia s c et h hr d eicr ee r in s a m e ic ie hsits e r ot . opa wr e r d l e p e – D sit t f tht eicr cnitn o pr iptn epe h a t Md a odios fa ic a e c a e t io r ue c eteotg m shah a e ir inidn r r in ot el cr q p in t e ogn a n ( log nt a bloy r te) r izt sahuh o in mu trpa ics a io t a c .
  • 8. A R Ptn Sfy gn a n ( S ) H Q’s a ta tOr izt sPOs ie e a io Cet b t Ptn Sfy a ymrvmn A t f r e yh a t a tQul Ipoe et co ad e ie e it 20 ( a n Sfy c , POs 05 Pt t a tA t S ie e ) – Al hah a poidrt clcad nle a whu lw el cr rv e o oetn aaz dt it t o t e s l y a o f r f glis vr e o l ad c e a e o y – Mspoeth pivc o ptn ad eotg ut rt t ray fa t n r r c e ie s p in ogn a n. r izt s a io • C r nyhr a 7 POsis d it A R ur t t e r 5 S le wh H Q. el e e t – Sosrinl e opaa oia n, hah y e s p nos c d hsit s ct s el s t , u l s io t sm cl oa n o hah y e sinl in aae ic eicl oa r ios fel s t ( c d g cdm md a l t b t sm u cn r ntnla togn a n ad nlic vnos et ) a ase r izt s n aats edr e , io fy a io y , l il inue , po s nls ctn, ad inlis e ia it sr s rf s aa oia s n sg s by r e io s io e u sosr( .gmd a n a t aet s l yad l d pnose . eict se , ns eio g, n b o io fy h o o bns ak . )
  • 9. C m o Fr a ad eotg o m n omt n R p r s in • A R hsr t t C m o Fr a ( F v .2o A H Q a c a d h o m n omt C s 1 f E ee e s ) r r otg sg t c r dt dsndo r otgo e r uin sut e a , eige f e r t p in r ud a r p in ml lsucs uip or . te e – A R PO Pivc Poetn et hs C s n r oe H Q’s S ray rt io C n r ot F ad e vs c e s m idn ialin r a n oa w a ag gtn t N tok f et b f mt t l dt gr a in h e ro if e o io l o a e io e w Ptn Sfy a bss a t a tD t a . ie e a e • Poidrmy l ue F t sn r ott s t aec s rv e a ao s C so ed e r o te gnie s s p s a ad h Fo ad rg d int tn n t o d n D u A m isa . e r io
  • 10. I r sd e ne n S n e e riac o POs ca l • T eOM 21 r ot e lt ITa dP t n Sf t : h I ’s 01 e rH a h n aie t aey p B ild gSf rS t m f rB t e C r r o mne u in ae y e s o et r ae e m edd s c vl t yeotg y rv e t POs sg H Q’s o n rr r b poidr o S uin A R u a p in s C m o Fr a a “bso tn o m n omt s et p .” s io • U drh A A b 21 a opat tot c wh ne t C , y 04 hsit h cn at it a e la r s hah l t t a ic a s a inuac ecag is el p n h pr ipt in n sr e xhne t a a t e n r ue t hv a a n se ea a n y e t t e ir o ae pt ta t vl t s t h q d ie fy u io s m a inl e r otgoPOs c dse r t S . u p in
  • 11. T e hlne h Ca g l e D vl a ap a n htail t te ee p n pl t taf it e h o ic io c as rp r g fa n s e eet eot o pt ta t vns in ie f y , we e iml et in op ao ht r p mne h sit r h e d l a bloy e ins mu tr st g a t .
  • 12. D s ip n A p hu . . . ec t : p sol r io d • I r s t es o r otg a n se eett t n e e h a fe r pt ta t vn o h ca e e p in ie fy s e poidr r a n ogn a n rv e o pr t r izt ; e a io • Ealpoidrt imote vn E RP Rad t r nb rv e o p rreat M , H , n oh e s l e e c oic f mtninl in s en ht t t l t n in r a , c d g c e sos o h er o io u r , e ptn se r otn, in unsb itn H Q a ta t e rad t , um a A R ie fy p r C m o Fr a - o p n r otooe r oe o m n omtcml te rt n o m r s ia p POs S ; • C p r ue le or h ad t re vn at e sf dm g pic n oh reat u u a e l in r a nrm ah a n inl in aegne r e f mt f ec pt t c d g g, edr a , o io o ie u , c ad e vn d goe; n reat ianss l
  • 13. A p hu . . .( ot) p sol cn d ’d • C p r in r a n b u t t e f r n a n at e f mt aoth y o og izt u o io e p a io sb it gh r ot sg H Q's S Iomtn umt t e ruin A R PO n r a in e p f io f mt o a r • R dc bre o r otg y nb gh o tn f eue udn fe r b eal t p o p in in e io sb it g f mtn t ptn se r oto umt in r a in h a ta t e rt in o io e ie fy p pb hah r el oe igt r n a n, inl in ul el o hah vr h og izt s c d g ic t t s a io u s t o f e lrg m o ac din o cr y g te re r por s rcr itg re if a da a e t in bd s o ie. • B p t r - got; e lf mans ao ic • Lvr e n et d w I s na s n sr e ee g ad x n N HN t dr ad e ics a e a d v inl in, bt o l it t, t np r( ir t e c d g u nt e o r sotD e , wb u im d a c sr e) cn n ( r sios f a , C DC R, ad e ics ot tTa itn o C r C /C ) n v , e n e s na izd oau rs t dr e vcblie. a d a
  • 14. R sucs eore • Iomt n n S ad o m n omtis n r a o POs n C m o Fr a f io s aaalah p/w .po hq o/ vil e t t :/ w s.ar.gv b t w • T e o m n omtv .2 aaalo te S h C m o Fr a 1 is vil e n h PO s b Pivc Poet n et wbit a r ay rt io C ne ese t c r hts/w .po p.og e/ tns e t :/ w spc r/ b a t f y p w w p ie a t
  • 15. J g g re u in Cit ia d r 1. Ef civ n s o t esse inf c ain p t n s f t fe t e e s f h y t m a ilit t g aie t aey e e t rp rin in lu in it c m lia c w hA R ’s v n e ot g c d g s o p n e it H Q C m o F r as o m n om t 2. U a ilit a dd s nf o t esa d o t o a s b y n e ig rm h t n p in f ll sa e o es t k h ld r 3. A ilit t ine r t w he crn h a hrc r sa doh r b y o t gae it le t o ic e lt e od n t e H d t suc s IT aa o re 4. Ce t it a din o aio raiv y n n v t n 5. L v r g N H sa d r sin lu in t a s ot c ne t e ea e w IN t n ad c d g r n p r, o t n, a dv c b laie n oa u r s
  • 16. T ee iml in • Sb is n eio bg sJ e21 um s pr d ein: u , 02 io n • Sb is n e d ns uut 121 um s pr ed: A gs3, 02 io io • W nranucd Sp me 21 ine none: et br 02 s e ,
  • 17. Q uestions? w w el2hlne r w .hahca g.og t l e C ontact Jean-Luc N eptune at: j el 2o .cm l ahcn o @h t

Editor's Notes

  1. It is difficult to fix problems you do not know about.
  2. Often PSOs collaborate. Often a PSO will hire another entity to do the backroom analytics. Providers may want to send reports to more than 1 PSO. Maintaining the privacy and confidentiality of “patient safety work product” (PSWP) under the Patient Safety Act requires careful treatment of data.
  3. 26 states have some form of mandatory adverse event reporting. Hospitals are required to report serious injuries involving regulated medical devices to the FDA. AHRQ has also created the Network of Patient Safety Databases to collect non-identifiable AE reports in the Common Formats, as a research database.
  4. Providing education and resources to help reduce fat and salt intake, increase exercise, lose weight, stop smoking, or increase medication adherence (e.g., to improve control of high blood pressure) Using GPS technology to recommend nearby walks or places to eat healthier Recommending to the high risk patient to see a primary care doctor if not on aspirin or cholesterol-lowering medication Linking to online communities dedicated to improving heart health