Instilling a culture of patient safety involves creating an open atmosphere for reporting and addressing safety risks and for anticipating and preventing errors, as well as redesigning patient care systems.
At the recent World Healthcare Innovation & Technology Congress meeting in Washington, D.C., executives from Rhode Island hospital systems described how a new Web-based reporting system being rolled out in the Ocean State is central to creating the first statewide patient safety organization (PSO), a data repository with protected information allowing hospitals to aggregate, trend, and benchmark data. (The creation of the Rhode Island PSO was mandated and funded by the state legislature in 2008, due to some high-profile surgical errors in the state.)
When Congress passed the Patient Safety and Quality Improvement Act of 2005, it authorized the creation of PSOs to encourage clinicians and healthcare organizations to voluntarily report and share quality and patient safety information without fear of legal discovery. Final regulations for PSOs were published in early 2009. Since then, 85 such organizations have been created, many by specialty practice groups and hospital associations. But Rhode Island’s is the first statewide PSO, according to Mary Reich Cooper, M.D., J.D., senior vice president and chief quality officer of four-hospital Lifespan Corp., based in Providence.
Mary Reich Cooper
Tracking Safety Trends
The new statewide implementation of Medical Event Reporting System (MERS) software from GE Healthcare will make it easier to track trends, understand root causes and implement changes, Cooper said. A statewide system will allow hospitals to learn from each other’s near misses and process improvements, she added.
Eventually all 16 hospitals in Rhode Island will report data through the MERS to a national network of patient safety databases, which will lead to the creation of an annual federal report about patient safety occurrences.
Cooper said MERS “improves the transparency of medical event reporting and speeds routing of events to stakeholders.” It improves documentation of the communications related to an event and the improvements implemented, she added. Staff members can enter events quickly into the Web-based database using standard forms, and managers and administrators can sort, analyze and track actual and near-miss events.
Complexity Around State PSOs
Creating a statewide PSO is much more complicated than tracking patient safety within one organization, according to Jean Marie Rocha, MPH, RN, vice president for clinical affairs for the Hospital Association of Rhode Island. “The previous state reporting system had no common definitions,” she said. In five working sessions from March to July 2010, hospital officials met to standardize more than 100 definitions for categories such as events and near misses, pharmacy services and medication safety and employee events.
The MERS rollout started in mid-2010, and all Rhode Island hospitals are expected to have implemented the system in early 2011.
“The early feedback from hospital staffers is that MERS is the best thing since sliced bread,” Rocha added, because the reporting is mapped to the organizational structure so reports get routed automatically to managers and administrators.
States such as Rhode Island and Delaware have made early progress in health IT because their size allows stakeholders to work closely together on governance issues. But Cooper said other states would benefit from starting to work on state-level PSOs as well.