Patient Safety

ZeroHarm

Clinical excellence is a top priority for Missouri hospitals to provide safe and high quality of care with a patient and team-centered approach. There is continuous quality improvement, and Missouri hospitals are participating in many statewide and national initiatives to improve care and safety. These include efforts with patient falls, infections, ventilator-associated pneumonia and reduction of surgical site infections. MHA has partnered with VizientTM Patient Safety Organization to provide a full suite of expertise, tools, a system for data collection and resources.

  • VizientTM PSO
  • Background
  • Regulatory
  • Glossary
  • FAQs
  • Resources
PSO calendar snipThe Missouri Hospital Association, Vizient Patient Safety Organization and Healthcare Services Group will provide a full suite of expertise, tools and offerings to improve quality, patient safety and care coordination. This comprehensive program elevates hospitals’ patient safety initiatives through a wide range of patient safety activities, including:
  • Best practices exchange – networking opportunities, webinars, annual meeting and quarterly calls
  • Legal protections – services that maximize available legal protections
  • Tailored solutions – customized PSO applications and solutions to meet unique hospital needs

Vizient Fact Sheet

Vizient PSO MHA Quarterly Report June 2017
The quarterly report was created for the Vizient PSO members through the Missouri Hospital Association. This document includes the following information:
  • Overview of PSO data
  • Reducing falls with injury
  • Direct oral anticoagulants
  • Safety huddle pilot
  • ISMP self-assessment
  • Upcoming PSO events

NEW! Download the 2017 PSO Calendar. Contact Jessica Schoenthal, Collaborative Advisor for the Vizient PSO, to register.

Click here for more information.

What is a PSO?

A patient safety organization is a group, institution or association that improves medical care by reducing medical errors. In the 1990s, reports in several countries revealed a staggering number of patient injuries and deaths each year due to avoidable adverse health care events.

The Patient Safety Act authorizes AHRQ to list or designate entities as patient safety organizations that attest to having expertise in identifying the causes, and interventions to reduce the risk, of threats to the quality and safety of patient care. The work of a PSO is not directed by AHRQ. PSOs essentially serve as contractors to providers, and a PSO’s activities for a provider are usually determined by the Patient Safety Act contract entered into by the parties.

The Patient Safety Act establishes criteria for an entity or a component of an entity (component organization) to seek listing as a PSO by AHRQ. The primary activity of an entity or component organization seeking to be listed as a PSO must be to conduct activities to improve patient safety and health care quality. A PSO's workforce must have expertise in analyzing patient safety events, such as the identification, analysis, prevention, and reduction or elimination of the risks and hazards associated with the delivery of patient care. See Patient Safety Rule Section 3.102 for the complete list of requirements.

Need and Value of a PSO

PSOs serve as independent, external experts who can assist providers in analyzing data that a provider voluntarily chooses to report to the PSO. Providers that work with a PSO can benefit from the ability of PSOs to aggregate data from all of the providers reporting to the PSO, enabling many PSOs to develop the large numbers of patient safety events essential for identifying the underlying causes of infrequent, but often tragic, adverse events.

The Patient Safety Act and rule provide protections that are designed to allay fears of providers of increased risk of liability if they voluntarily participate in the collection and analysis of patient safety events. The uniform federal protections that apply to a provider's relationship with a PSO are expected to remove significant barriers that can deter the participation of health care providers in patient safety and quality improvement initiatives, such as fear of legal liability or professional sanctions.

Patient Safety Act — The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) amended Title IX of the Public Health Service Act. The statute provides for the improvement of patient safety and the reduction of the incidence of events that adversely affect patient safety.

Patient Safety Rule — The Patient Safety and Quality Improvement Final Rule (Patient Safety Rule) establishes a framework by which hospitals, doctors and other health care providers may voluntarily report information to PSOs, on a privileged and confidential basis, for the aggregation and analysis of patient safety events.

Notice of 2008 Proposed Rulemaking — This document proposes regulations to implement certain aspects of the Patient Safety Act. The proposed regulations establish a framework by which hospitals, doctors and other health care providers may voluntarily report information to PSOs, on a privileged and confidential basis, for analysis of patient safety events. The proposed regulations also outline the requirements that entities must meet to become PSOs and the processes for the secretary to review and accept certifications, and to list PSOs.

Click here to download the PSO glossary.


Adverse Drug Event (ADE)
An adverse event involving the use of medications or the failure to use appropriate medications when indicated.

Administration Error
An error in the phase of the medication use process where the drug product and patient interface.

Adverse Drug Reaction (ADR)
An adverse effect produced by the use of a medication in the recommended manner. ADRs may range from \"nuisance effects\" (e.g., dry mouth with anticholinergic medications) to severe reactions, such as anaphylaxis to penicillin.

Adverse Event (AE)
Any injury caused by medical care. An adverse event does not imply error, negligence or poor quality care, but indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process.

AHRQ
Agency for Healthcare Research and Quality www.ahrq.gov

Benchmark
In health care, a benchmark is the best in industry measurement that can lead to superior performance. Three principles of benchmarking are maintaining quality, customer satisfaction and continuous improvement.

Call Out
A strategy used to communicate important or critical information.

Close Call
An event or situation that did not produce patient injury, but only because of chance. The close call may be attributed to the robustness of the patient or a fortuitous, timely intervention. Close calls are also called “near miss” incidents.

CPOE (Computerized Physician Order Entry)
A computer based system for ordering medications and/or other tests in which physicians directly enter orders into a computer system.

Crew Resource Management (CRM)
A range of approaches to training groups, originally developed in aviation, to function as teams, rather than as collections of individuals that emphasizes the role of "human factors" and the impact of different management styles and organizational cultures in high-stress, high-risk environments. Also referred to as Crisis Resource Management.

Critical Incidents
Significant or pivotal occurrences in which significant harm or potential for harm occurred and have the potential to reveal important hazards in the organization and individual that can be remedied to prevent similar incidents in the future.

Culture of Safety
The result of an organizational commitment to safety permeating all levels from front-line personnel to executive management. Features of a culture of safety include acknowledgment of the high-risk, errorprone nature of an organization’s activities, a just environment where individuals are able to report errors and near misses without fear of reprimand or punishment, an expectation of collaboration across ranks to seek solutions to vulnerabilities and a willingness on the part of the organization to direct resources for addressing safety concerns.

Dispensing Error
Deviations from the prescriber’s order, made by staff in the pharmacy when distributing medication to nursing units or to patients in ambulatory settings.

EHR
Electronic Health Record

Error
An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome.

Event Reporting
The identification and reporting of occurrences that could have led, or did lead, to an undesirable outcome, typically from personnel directly involved in the incident or events leading up to the event. Also referred to as “occurrence reporting” or “incident reporting.”

Failure Mode and Effects Analysis (FMEA)
A method to prospectively analyze errors to predict the likelihood of a particular process failure. Also combines an estimate of the relative impact of the error to produce a "criticality index" to allow for the prioritization of specific processes as quality improvement targets. Each step in a process is assigned a probability of failure and an impact score, so that all steps could be ranked according to the product of these two numbers. Steps ranked at the top (i.e., those with the highest "criticality indices") should be prioritized for error proofing.

Hazard Analysis
Process used to determine the potential severity of the loss from an identified risk, the probability a loss will happen, and alternatives for dealing with the risk. Also referred to as Risk Analysis.

Health Literacy
The ability of an individual to find, process, and comprehend the basic health information necessary to act on medical instructions and make decisions about their health.

High Alert Medications
Drugs that bear a heightened risk of causing injury when misused, consequences of errors with these drugs may be more devastating.

High Reliability Organizations (HROs)
Organizations or systems that operate in hazardous conditions but conduct relatively error-free operations. Examples of HROs are air traffic control systems, nuclear power plants, and naval aircraft carriers. Studies reveal HROs have 5 common features, including a preoccupation with failure, resists over-simplification, commitment to resilience, sensitivity to operations and looks to expertise not rank to inform decisions.

HIT
Health Information Technology

Human Factors (or Human Factors Engineering)
The study of human abilities and characteristics as they affect the design and operation of equipment, systems, and jobs, includes considerations of the strengths and weaknesses of human physical and mental abilities and how these affect the systems design.

IHI
Institute for Healthcare Improvement www.ihi.org

Incident Reporting
The identification and reporting of occurrences that could have led, or did lead, to an undesirable outcome, typically from personnel directly involved in the incident or events leading up to the event. Also referred to as “occurrence reporting” or “event reporting.”

ISMP
Institute for Safe Medication Practices www.ismp.org/

Just Culture
A culture in which front-line personnel are comfortable disclosing errors, including their own, while maintaining professional accountability, recognizing individual practitioners should not be held accountable for system failings over which they have no control, yet does not tolerate conscious disregard of clear risks to patients or gross misconduct.

Latent Error (or Latent Condition)
An error resulting from organizational factors or systems, literally “accidents waiting to happen,” errors at the “blunt end,” referring to layers of the health care system that affect the person providing direct care to patients, at the “sharp end.”

Medical Emergency Team - MET
A team, similar in concept to a cardiac arrest team, with more liberal calling criteria for responding to a wide range of worrisome, acute changes in patients’ clinical status, such as low blood pressure, difficulty breathing, or altered mental status, de-emphasizing the traditional hierarchy in patient care, allowing anyone to call for the team. Sometimes referred to as a Rapid Response Teams.

Medication Reconciliation
A process to review patients’ medications at the time of transfer to another level of care or discharge and comparing them with medications prior to hospitalization or transfer in order to identify and address discrepancies.

Medication Safety
Freedom from accidental injury during the course of medication use; activities to avoid, prevent, or correct adverse drug events which may result from the use of medications.

Near Miss
An event or situation that did not produce patient injury, but only because of chance, also called a “close call.”

NPSF
National Patient Safety Foundation www.npsf.org

NPSG
National Patient Safety Goals - goals established by The Joint Commission to help its accredited organizations address specific areas of concern in regards to patient safety. www.jointcommission.org/standards_information/npsgs.aspx

NQF
National Quality Forum www.qualityforum.org

Occurrence Reporting
The identification and reporting of occurrences that could have led, or did lead, to an undesirable outcome, typically from personnel directly involved in the incident or events leading up to the event. Also referred to as “event reporting” or “incident reporting.”

Patient Safety
Freedom from accidental or preventable injuries produced by medical care; activities to avoid, prevent or correct adverse outcomes which may result from the delivery of health care.

PHI
Personal Health Information

Prescribing Error
Mistakes made by the prescriber when ordering a medication.

Read-Backs
A process or protocol by which the listener repeats key information back to the transmitter of the information, so that the transmitter can confirm its correctness.

Red Rules
Rules that must be followed to the letter, relate to important and risky processes, must be simple and easy to remember, should be known organization-wide, should foster a culture of patient safety.

Risk Analysis
Process used to determine the potential severity of the loss from an identified risk, the probability a loss will happen, and alternatives for dealing with the risk. Also referred to as Hazard Analysis.

Risk Assessment
Qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences.

Risk Identification
Process used to identify situations, policies or practices that could result in the risk of patient harm and/or financial loss to the institution.

Risk Management
Clinical and business techniques employed to prevent or reduce risk of injury to patients, staff, visitors, and prevent or reduce organization losses and preserve the organization’s assets.

Root Cause Analysis (RCA)
A structured process used to identify causal or contributing factors underlying adverse events or other critical incidents, uses a pre-defined protocol for identifying specific contributing factors in various causal categories (e.g., personnel, training, equipment, protocols, scheduling) resulting in a detailed account of the events that led up to the incident to assist in identifying areas of focus for improvement to prevent the event from reoccurring.

Safety Culture
The result of an organizational commitment to safety permeating all levels from front-line personnel to executive management. Features of a culture of safety include acknowledgment of the high-risk, errorprone nature of an organization’s activities, a just environment where individuals are able to report errors and near misses without fear of reprimand or punishment, an expectation of collaboration across ranks to seek solutions to vulnerabilities and a willingness on the part of the organization to direct resources for addressing safety concerns.

SBAR
A standardized method of communication between patient care providers including explanation of the situation, background, assessment and recommendations. This tool helps individuals communicate in a concise and structured format with a shared set of expectations. It also improves efficiency and accuracy.

Sentinel Event
Term used by The Joint Commission to define an adverse event in which death or serious harm occurred, usually referring to events that are unexpected or unacceptable.

Situational Awareness
The degree to which one’s perception of a situation matches reality. Maintaining situational awareness might be the equivalent of keeping the “big picture” in mind.

Six Sigma
A metric that indicates how well a process is performing. The higher the sigma value, the higher the performance quality of the organization’s process. Sigma measures the capability of the process to perform defect-free work, with a defect being anything that results in customer dissatisfaction. Six sigma targets a defect rate or level of quality that only permits 3.4 errors (or variations) per million opportunities, 6 sigma. Six sigma typically strives for quantum leaps in improvement.

STEP
A tool for monitoring situations in the delivery of health care – Status of the patient, Team members, Environment, Progress toward goal.

Swiss Cheese Model
James Reason’s Swiss Cheese Model has become a dominant paradigm for analyzing medical errors and patient safety incidents. The model illustrates how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. Each slice of cheese represents a safety barrier or precaution relevant to a particular hazard with no single barrier being foolproof. In health care many of the slices of cheese already have their holes aligned so one slice of cheese may be all that is left between the patient and the significant hazard.

System
Interdependent elements (human and non-human) interacting to achieve a common aim.

System-thinking
An approach to risk prevention that looks at how individual processes connect or are interrelated and how flaws in the process or “system” may be at the root of many, seemingly unrelated events that result or have the potential to result in human injury. It provides a framework for seeing changing patterns and structures that underlie complex situations.

Systems Approach
An approach with the view that most errors reflect predictable human failings in the context of poorly designed systems (e.g., expected lapses in human vigilance in the face of long work hours or predictable mistakes on the part of relatively inexperienced personnel faced with cognitively complex situations).

Rather than focusing corrective efforts on reprimanding individuals or pursuing remedial education, the systems approach seeks to identify situations or factors likely to give rise to human error and implement "systems changes" that will reduce their occurrence or minimize their impact on patients. This "systems focus" includes paying attention to human factors engineering, including the design of protocols, schedules, and other factors that are routinely addressed in other high-risk industries.

TeamSTEPPS™
Patient safety training offered by AHRQ - Team Strategies and Tools to Enhance Performance and Patient Safety www.ahrq.gov

Time Outs
Planned periods of quiet and/or interdisciplinary discussion focused on ensuring that key procedural details have been addressed. Taking the time to focus on listening and communicating the plans as a team can rectify miscommunications and misunderstandings before a procedure gets underway.

The Joint Commission
An independent, not-for-profit organization that accredits and certifies more than 15,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. www.jointcommission.org/

Transcription Error
An error in the phase of the medication use process that involves anything related to the act of interpreting an order by someone other than the prescriber for order processing. Transcription may be electronic or manual from the patient’s record.

Triggers
Signals for detecting likely adverse events. In many studies, triggers alert providers involved in patient safety activities to probable adverse events so they can review the medical record to determine if an actual or potential adverse event has occurred. In cases in which the trigger correctly identified an adverse event, causative factors can be identified and, over time, interventions developed to reduce the frequency of particularly common causes of adverse events. In these studies, the triggers provide an efficient means of identifying potential adverse events after the fact.

Underuse, Overuse, Misuse
Activities resulting in quality problems. “Underuse” refers to the failure to provide a health care service when it would have produced a favorable outcome for a patient. “Overuse” refers to providing a process of care in circumstances where the potential for harm exceeds the potential for benefit.

“Misuse” occurs when an appropriate process of care has been selected but a preventable complication occurs and the patient does not receive the full potential benefit of the service.

USP
United States Pharmacopeia www.usp.org

Is the PSO “listed” by AHRQ?
If the PSO is not listed, privilege and confidentiality protections of the Patient Safety Act will not apply. To find out if a PSO is listed, visit AHRQ’s website for Federally-Listed PSOs, updated weekly.

Yes. Vizient is listed with AHRQ and has consistently maintained its PSO status. Vizient was one of the first 10 AHRQ-listed Patient Safety Organizations in 2008.

Do you need a PSO that specializes in a particular area of care?
Some PSOs specialize by topic area, such as anesthesia or medication adverse events, while other PSOs may handle all kinds of patient safety events. Providers can opt to work with more than one PSO, depending on their needs.

Vizient collects and analyzes patient safety event types, specializing in events from health care providers across the continuum of care; general, specialty and critical access hospitals and academic medical centers, community health centers, group practices, ambulatory clinics, surgical centers, and ambulance services, among others. The Vizient PSO has over 250 participating members. (general, specialty, and critical access hospitals and academic medical centers, community health centers, group practices, ambulatory clinics, surgical centers, and ambulance services, among others). Reporting to a PSO helps to improve patient safety, healthcare quality and outcomes and accelerate the pace of improvement across organizations. Vizient PSO shares these learnings to help members prevent similar events in their organization. Greater participation by health care providers will ultimately result in identification of more opportunities to address the causes of adverse events, and improve patient safety.

Does the PSO provide direct assistance to its clients or does it use consultants?
Find out if the PSO’s expertise comes from internal staff or external consultants.

Vizient provides direct assistance, but also utilizes experts nationally.

What is patient safety work product?
PSWP is the data or documents assembled for and submitted to a PSO. PSWP is protected by the Patient Safety Act and the Patient Safety Rule. PSWP may identify the providers involved in a particular patient safety event and/or a provider employee that reported the information about the patient safety event. PSWP may also include patient data that is considered protected health information as defined by the Health Insurance Portability and Accountability Act Privacy Rule (see 45 CFR 160.103).

Examples of PSWP include subjective reports, staff impressions and/or other objective facts not part of mandatory reporting. Subject to certain specific exceptions, PSWP cannot be used in criminal, civil, administrative or disciplinary legal proceedings.

What documents might be considered PSWP?
The following documents ARE considered PSWP:
  • Peer review documents
  • Clinical practice protocols
  • Staff evaluations
  • Equipment review logs
  • Root cause analyses
  • Quality and safety reports
  • Committee minutes, deliberations or recommendations, checklists, notes or outcome data.

What documents would NOT be considered PSWP?
The following documents are NOT considered PSWP:
  • Patients records
  • Billing information
  • Mandatory reporting data
  • Discharge information
  • Information related to a criminal act
  • Original patient or provider information.

What are patient safety activities?
The following are the patient safety activities typically carried out by or on behalf of a PSO:
  • Efforts to improve patient safety and the quality of care delivery
  • The collection and analysis of PSWP
  • The development and dissemination of information regarding patient safety (i.e., recommendations, protocols, or information regarding best practices)
  • The use of PSWP as a means to encourage a culture of safety as well as for providing feedback to effectively minimize patient risk
  • The maintenance of procedures to preserve the confidentiality and security of PSWP
  • Activities related to the operation of a patient safety evaluation system
  • The provision of feedback to participants in a patient safety evaluation system

Do PSOs receive federal funding?
No, PSOs do not receive any federal funding.

Why are the terms safety and quality used together when describing the role of PSOs?
The term safety refers to reducing risk from harm and injury, while the term quality suggests striving for excellence and value. By addressing common, preventable adverse occurrences, a healthcare setting can become safer, thereby enhancing the quality of care delivered. PSOs create a secure environment where clinicians and healthcare organizations can collect and analyze data, thus identifying and helping to reduce the risks and hazards associated with patient care and improving quality.

What are the benefits to health care providers who work with a PSO?
PSOs serve as independent experts, who can collect and analyze PSWP on a local, regional and national level to develop insights into the root causes of patient safety events. Communications with PSOs are protected which helps to diminish fears of liability risk related to the analysis of patient safety events.

The protections of the Patient Safety Rule enable PSOs that work with multiple providers to examine the number of patient safety events that are needed to better understand the root causes of harm from adverse events and to develop more reliable information on how best to improve patient safety.

Patient Safety Organizations. (n.d.). Retrieved from http://www.pso.ahrq.gov/psos/fastfacts.htm.

How can providers access their data in the PSO?
Data will be password protected through a secure Web site as required by law. Providers will determine their unique permissions, which will either enable or limit access at a corporate or individual level.

How do I become a PSO member?
MHA member hospitals have the option of joining the PSO at any time by signing the Patient Safety Organization Service agreement. For more information contact Peter Rao or Tabatha Brightwell.

What is the cost of joining the PSO?
Standard participation fees will be paid for Missouri hospitals by MHA Management Services Corporation. Significant discounts will be extended to MHA members that join Vizient PSO for physician practices, EMS services, mental health facilities and their non-Missouri-based hospitals. These additional optional services and fees will be the responsibility of the participant.

Sample PSES Policies


Vizient, Inc.

American College of Healthcare Executives: Leading a Culture of Safety: A Blueprint for Success