Center’s Executive Director Comments on Recent Health Leaders Media on Event Reporting

June 24, 2015    |   By: Calevir

Read below Becky Miller’s comment to the recent Health Leaders Media Article, Never Event Frequency Troubling, Standards Lacking

This is such an important topic for discussion in healthcare. Here at the Center for Patient Safety, we offer another perspective. How can we learn as much as possible about what errors occur, why they occur and how to prevent them?  This can be accomplished by reporting not just sentinel or “never events” by a few types of providers, but reporting all errors plus near misses and unsafe conditions by all types of licensed providers.  After all, mistakes occur in any healthcare setting.  But, how can we do that?  Through a program established by the federal Patient Safety and Quality Improvement Act of 2005 (PSQIA) whereby organizations, called Patient Safety Organizations (PSOs), work with any healthcare provider licensed by a state in support of a culture to encourage reporting of errors and near misses and unsafe conditions, analyze reports, identify learning and share that learning; all aimed at error prevention. Reporting used by PSOs is based on Common Data Formats developed by the AHRQ. Yes, the PSQIA gives federal level legal and confidentiality protections to providers that report to a PSO. But importantly, that is not to prevent transparency as the protections still allow legal recourse for those harmed by error. This reporting encourages transparency within and among organizations so mistakes and problems that can lead to errors can be identified and reported. This enables the industry to learn, share the learning and proactively implement strategies to reduce error and harm. The goal is to encourage reporting and collaboration for the purpose of prevention, not publicizing what providers made how many mistakes and assigning blame.  As one of the first ten organizations to certify as a PSO with the Agency for Healthcare Research and Quality (AHRQ), we see the benefits of a voluntary program that supports a culture encouraging reporting of safety events. This is exciting work to improve safety for consumers and support providers in coming together to learn and share safety issues and concerns within and across organizations and providers. Evidence of the ability to learn through a voluntary and supportive culture is seen in the average number of annual reports the Center receives compared to those from the mandatory Minnesota program and The Joint Commission Sentinel Event Program; 20 times and 10 times more annual reports respectively. The level of reporting has a direct correlation with the level of learning and prevention that is possible through such programs. Additionally, PSOs obtain near miss and unsafe condition information, not just errors, from which more learning can be obtained as well as receive reports from many types of providers, not just those mandated to participate. Consider how we can balance efforts to inform consumers with accurate and meaningful information about patient safety and encourage and support reporting of errors and unsafe systems by providers. The work of PSOs is a solution to achieve this balance. Continuing to peel the onion of safety to get to the root causes must be encouraged, not shaming and discouraging providers from open reporting and discussion. Consumers may be interested to know if their healthcare providers work with other providers and a PSO to contribute to and share in the learning and prevention possible through this work. Providers and consumers can benefit from learning more about PSOs and how a sharing and learning culture can achieve everybody’s goal — reducing medical errors and preventing harm.


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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.