A note to CPS’ participants and friends:
The Florida Supreme Court has adopted a restrictive interpretation of the PSQIA as it relates to Florida’s risk management and discovery laws. Charles vs. Southern Baptist analyzes the relationship between the Patient Safety and Quality Improvement Act (the Act) and Florida laws that govern the development and protection of patient safety and quality material. The Court’s opinion is available here.
Providers in Florida need to get local legal advice about the extent of the state law impact on their safety and quality work, as this is the first step in applying Charles. Though the decision has no direct impact in other jurisdiction, it will be part of the ongoing discussion about PSO protections, so it is important to understand it. The key facts:
The Court held that patient safety work and the related reports, when required by state law, could not be PSWP, using the same analysis put forth by AHRQ in its Guidance last year. (AHRQ Guidance document available here.) Because the Charles information was collected or maintained for a purpose other than submission to a PSO or for dual purposes, the Court held it is excluded from the definition of PSWP contained in the PSQIA and the final rule.
This finding (that the requested information was not protected PSWP) is important when examining the next issue, whether the PSQIA pre-empts Florida Amendment 7. That provision eliminates any protection for “any records made or received in the course of business by a health care facility or provider relating to any adverse medical incident.” This discussion won’t delve into the detailed interaction of the PSQIA definitions and Amendment 7, though the relationship is complicated. The important thing for PSOs and their participants in other states is the Florida Court’s somewhat gratuitous finding that the PSQIA could not supersede or pre-empt Amendment 7.
CPS doesn’t recommend that its PSO participants assume that Amendment 7 has pre-empted the PSQIA. There are several reasons why PSO participants should not view this as established doctrine (or in non-legal parlance, a “done deal”):
Applying Charles:
CPS has always advised its participants to divide their safety and quality work into 3 categories:
Under Charles, documents produced to meet an independent state law requirement (Category 1) are not eligible to be PSWP. Work product that results from other state-required activities (Category 2) is in a gray zone and the answer may depend on state law and how you have structured the work. If you have questions, contact CPS. Review your mandatory activities and reports (bullets one and two above) and design your PSES to include work that is done outside those categories. Your PSES can always consider non-PSWP; the deliberations and analysis within the PSES can be protected, but the non-PSWP work product cannot.
There remains an open issue of admissibility in court for any of this information. That is another fight for another day.
CPS will keep you advised of new developments.
CPS will keep you advised of new developments.
This new report from the Commonwealth Fund offers lessons from hospitals that have not experienced any central line associated blood stream infections in their ICUs in 2009. These lessons include following evidenced based protocols, importance of a dedicated team overseeing central line insertions, value of participation in national and statewide collaborative, and the need for continued monitoring of infection rates and maintaining communication with staff about rates and goal achievement.
The Kansas Healthcare Collaborative, along with the Missouri Center for Patient Safety, co-hosted the Cohort 5 & 6 CUSP/Stop CLABSI Mid-Course meetings in Topeka, Kansas this week! Over 30 teams from Kansas and Missouri were in attendance and participated in group work on overcoming project barriers and walked through the process of learning from a defect.
Several Missouri teams were recognized for completing 6 or more consecutive months without a CLABSI in 2011, and teams from Cohort 2 in the Greater Kansas City area were recognized for completing the two year project. Congratulations to all the Missouri teams!
The MOCPS has been invited to lead a six-month course on the Comprehensive Unit-based Safety Program (CUSP) to over 70 Neonatal Intensive Care Units (NICUs) located throughout 7 states. All participating NICUs have joined a national collaborative sponsored by the Health Research Educational Trust (HRET) to stop central-line associated blood stream infections (CLABSIs). (more…)
Pride in our work! We think it really shows in our recently published report: 5 Years of Progress-2010.
Safety improvement involves everyone who drives the delivery of health care, and many have established important partnerships with the Center. Together, in just five years, we established the Center as a leader in PSO services, working with more than 180 providers to report medical mistakes, efficiently learn valuable information from those mistakes, and take actions aimed at prevention. (more…)
Along with representatives from 46 other PSOs, Becky Miller, MOCPS Executive Director, and Michele Hilburn, with Jefferson Regional Medical Center, attended the AHRQ PSO Annual Meeting in Rockville, Maryland, May 9-10. Michele provided a stellar presentation at a break out session at the request of AHRQ. She shared how Jefferson Regional has established its Patient Safety Evaluation System so that it may benefit from working with a PSO while meeting its own needs — an area that has proven challenging for providers and PSOs.
The below Tele-Forum segments, hosted by KCPT’s Nick Haines, include patient safety experts, Judy Baker, Dr. Sean Berenholz, David Marx, Becky Miller and Diane Cousins, whose brief and information-packed discussions trigger a wide variety of potential news stories.
A consistent and key goal for the Center is patient safety awareness within the health care industry, for the media and the general public. We intensify our awareness and educational efforts each year in the month of April to further increase the use of patient safety language and cultural practices professionally and publicly.
The Center is so proud of our friend, colleague and faculty member, Pat Posa RN, BSN, MSA, for her leading role in earning the US Department of Health and Human Services Outstanding Leadership Award for St. Joseph Mercy Hospital in Ann Arbor, Michigan! Pat is the System Performance Improvement Leader at St. Joseph Mercy Health System.
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As a federally designated Patient Safety Organization (PSO), MOCPS is part of a national program which will have reduced preventable adverse events by 3% within the first five years of operations of PSOs, according to estimates from the federal Department of Health and Human Services, saving $435 million in national health care costs.
Safe Health Care – What Missouri Providers are Doing for You
An estimated 250,000 central line-associated blood stream infections (CLABSIs) occur in hospitals each year, and as many as 62,000 patients who get these infections die as a result. (more…)
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.