The latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!
A NEED FOR SPEED
Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4
THE ORANGE DOOR
Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6
A UNITED FRONT TO IMPROVE CARE
What the AHRQ guidance means for providers and their patients. 11
PSO LEGAL UPDATE:
Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15
EMS UPDATE:
New CPS report seeks to raise awareness of safety concerns in the EMS community. 16
ALSO IN THIS ISSUE:
CPS again thanks Michael Callahan for sharing PSQIA current events. The case is Johnson v. Cook County, N.D. IL, Eastern Division, No. 15 C 741, 2015 WL 5144365; available at https://casetext.com/case/johnson-v-cook-cnty-3.
The first thing to note is that the federal court refused to apply the state peer review protection statute, a common occurrence. One of the reasons we celebrate the PSQIA is that without it, litigants in federal court often have no strong protection. Another interesting aspect of the case arises from the venue of care: the county jail. Because the plaintiff alleged systemic failures in the correctional system, the court distinguished the case from an ordinary state malpractice action and evaluated it as a federal civil rights issue.
This is the first case that looks deeply at functional reporting, the provision in the Final Rule that can protect information that has not been submitted to the PSO. The Court held that the defendant (Cook County) did not meet its burden of establishing that the information at issue was protected Patient Safety Work Product. The contract between the defendant and its original PSO defined all peer review work as “functionally reported” in the sense that it gave the PSO access to the information. However, the defendant could not (or at least did not) produce any other information suggesting that it had reported anything to the PSO.
The court’s language is worth noting:
Defendant essentially is asking the Court to presume, with no supporting documentation, that it (1) maintained a patient safety evaluation system, (2) made the Report part of its patient safety evaluation system, and (3) provided [the PSO] access to its patient safety evaluation system. In other words, Defendant is asking the Court to presume Defendant complied with the PSQIA’s reporting obligations by virtue of presenting the Court with a copy of a contract. That is not enough.
Defendant has not shown in any way that the Report was generated with a PSO or patient safety evaluation system in mind… Nowhere does the Policy mention the report will be provided to a PSO or a patient safety evaluation system, that the review and report are completed for the purpose of providing information to a PSO or patient safety evaluation system, or even that a PSO will have access to the report.
These issues will sound familiar to CPS participants, who are probably tired of CPS staff haranguing them to complete their policies and submit reports. But this case now joins others that require evidence of a valid PSES. These take-aways, adapted from Michael Callahan’ suggestions, should also be shared with any attorney defending a PSO participant:
PSOs and providers need to work together when faced with these discovery challenges.
CONTACT CPS FOR ADDITIONAL SUPPORT
November 17 @ 12pm CST – Free webinar
Confused about Patient Safety Organizations (PSOs)? You’re not alone!
Join the experts at the Center for Patient Safety as they describe the basics of the Patient Safety and Quality Improvement Act (PSQIA) and provide an introduction to the terminology and concepts of PSO participation. Applications to EMS, LTC, medical offices, and hospitals will be presented. Q&A available during webinar. Register
Cases interpreting the Patient Safety and Quality Improvement Act (PSQIA) continue to wind their way slowly through the courts. Two new Florida trial court orders have recently reinforced the strength of PSQIA protections in that state: the cases are:
Loyless v. Flagler Hospital et al., No. CA12-2401 7th Judicial Circuit, St. Johns County, FL
PETRASKIEWCHZ v. Laser Spine Institute et al., No. 13-CA-14394 13th Judicial Circuit, Hillsborough County FL (August 10, 2015)
The Loyless order is very short. The court conducted an in camera review of the documents requested by the plaintiff and held that the documents were protected PSWP. It reinforces earlier advice from CPS that participants should anticipate that a judge may want to look at the materials for which they claim protection.
The Laser Spine Institute (LSI) court produced a more extensive order that analyzes the intricacies of Florida law. Florida courts have produced some challenging decisions in the past. The opinion discusses the history of the PSQIA, including quotes from the Final Rule and Congressional Hearings leading up to the law.
Briefly, the LSI court held that 1) the PSQIA supersedes Florida’s Amendment 7 and 2) a provider can prepare PSWP separate from the mandatory state reporting system and claim PSQIA protection for its PSWP.
Highlights of the LSI case
The Center for Patient Safety has released the 2014 PSO Report, containing findings reported by healthcare providers.
The data contained in the report is from the Center for Patient Safety’s PSO database. Licensed healthcare providers may participate in a PSO in order to share information, learn from the sharing, gain federal protection to support open reporting and ultimately reduce mistakes and patient harm. PSO participation is voluntary and organizations may choose to submit most or all adverse events or they may choose to submit only the more severe adverse events to share lessons learned. The event types and their severities, along with additional information, contained in the report are deidentified as required by the PSQIA.
The goal of the report is to present an overview of the findings within all of the events reported to the Center’s PSO, to learn how and why events are occurring, and inform providers and others about how to prevent future occurrences.
General CPS findings include: (more…)
Now that Patient Safety Organizations (PSOs) have been in existence for more than five years, the federal Patient Safety and Quality Improvement Act (PSQIA) is better understood, and knowledge about the Act has increased. Still, there are a number of questions we commonly receive at the Center for Patient Safety. Here are the top 10 questions, answered by the Center’s Patient Safety Specialist, Eunice Halverson at [email protected]:
Why should a health care provider join a PSO?
PSOs are independent, external experts who can collect, analyze and aggregate patient safety work product to develop insights into the underlying causes of patient safety events. Communications with PSOs are protected to allay fears of increased liability or fear of sanctions. With this federal protection, healthcare providers can share information with other participants, via the PSO, and learn from each other to ultimately improve patient care. More information is available from the AHRQ on working with a PSO.
The latest newsletter from the Center for Patient Safety has been released. The Fall 2014 EMS PSONews contains information on the recently released PSO Safety Alert and EMS Safety Watch, articles on the legal environment to help maximize federal protections from the PSO, patient safety culture topics, and much more! Download the newsletter or view on Issuu.
WEBINAR!
Date: October 1, 2014
Time: 11:30-12:30 Central
Cost: FREE
Suggested Attendees: EMS Leadership including Board Members and legal representatives
Please join us for a special webinar featuring Kathy Wire, JD, MBA, CPHRM, Center for Patient Safety (CPS) attorney, on October 1, 2014. This event is an opportunity to learn more about CPS and how your agency can benefit from participation in a Patient Safety Organization (PSO).
Did you know there is little to no legal protection for peer review or safety and quality improvement work in EMS? The CPS is a Federal listed PSO that offers you and your service protection for this important work.
The Kentucky Supreme Court has issued its anxiously awaited opinion in Tibbs, et al. v. Bunnell (2012-SC-000603-MR). The opinion is available online here. Earlier in the case, the Kentucky Court of Appeals ruled that only work reflecting “self-examining analysis,†could be protected PSWP, eliminating data or reports used as part of that analysis from protection. The hospital appealed, with support from the national PSO community. The Kentucky Supreme Court rejected that restriction based on the language of the law and final rule. It went on to examine the definition of PSWP as applied to the information sought by the plaintiff, which included incident reports. (more…)
A Florida trial court order regarding the discovery of hospital incident reports is circulating in PSO circles. (Charles v. Southern Baptist Hosp. et al., Duyal County, Case No. 15-2012-CA-002677.) The order expresses a very restrictive view of PSWP (more below) and the hospital has expressed an intention to appeal the order. As a trial court order in Florida, it has no value as precedent in any other jurisdiction, even within Florida. However, the order will be part of the ongoing discussion about PSO protections, so CPS wants its stakeholders to understand it. The key facts:
A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour
The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis
Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with
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.