Transcript Document

Refresher
Research Coordinators Mtg
P
S
N
Patient
Safety
Net
02/27/12
Table of Contents
1
Introduction
2
Use of Patient Safety Net at the
SCCA
3
Patient Safety Net Access
4
Navigating through PSN
Use of Patient Safety Net
What is Patient Safety Net® (PSN)?
PSN is an anonymous online reporting system used at the Seattle Cancer Care
Alliance.
PSN is used to track events that occur at the SCCA such as:
– Unsafe Conditions: Environmental factors or work processes that have a
potential to harm a patient/visitor*.
– Near Misses: Events that do not reach the patient/visitor but had the
potential to harm or inconvenience the patient/visitor if it had not been
corrected before reaching the patient/visitor.
– Events that Reach the Patient/Visitor: Events that reach the patient/visitor
causing harm or inconvenience.
*Visitor refers to a patient’s family member or caregiver.
Please Note! We do not use PSN to track events that reach staff, if you slip, trip, or
have a needle stick, please report those using an Accident Illness Report form.
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Use of Patient Safety Net
The Role of PSN at the SCCA
Learning from Events, Near Misses, and Unsafe
Conditions is key in monitoring and improving our
process for safety and efficiency.
o A system flaw or gap can go undetected without your PSN
report.
o When an error occurs, the review often uncovers system
vulnerabilities that could be improved upon.
o Learning from PSN events help the SCCA to build better
systems to promote patient safety and support your work.
o The ultimate goal is to protect patients from harm.
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Use of Patient Safety Net
Some Examples of Event Reports:
– Medication Events
• Medication Delays
– Laboratory or Specimen Events
• Not Completed
• Results Delayed
– Patient/Visitor Falls
– Communication/Care Coordination Problems
• Scheduling Issues
• Unclear Orders
– Equipment, Supply, or Device events
– Environmental Hazard
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Patient Safety Net Access
PSN Account Access
• All staff have the ability to enter a PSN.
• Access to PSN is granted by using your UW AMC/IRIS
Logon information (also known as your
Orca/Mindscape password).
• If you do not have an AMC account, work with your
manager to fill out the PSN access request form
found at O:\Computer Applications Access forms.
• PSN is accessed via the link:
• https://psn.medical.washington.edu/login.aspx?Re
turnUrl=%2fdefault.aspx
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Patient Safety Net Navigation
Operation of PSN
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Patient Safety Net Navigation
Entering and Event
• PSN Icon is located on all SCCA Clinic
Desktops and identified by this icon
• Research Staff not in the clinic access via the
following Link (saved to favorites or manually
as a link on desk top)
• https://psn.medical.washington.edu/login.as
px?ReturnUrl=%2fdefault.aspx
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Patient Safety Net Navigation
Concepts to Remember When
Entering an Event
• The intent of PSN is to track system issues in patient
care, not to finger point.
• When entering an event, be as objective as possible.
• PSN events can be reported anonymously. If you do
not document your name at the end of the report,
you will not be identified as the reporter.
• Enter “Research Patient” as the first two words in
the event description.
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Patient Safety Net Navigation
Navigating Through PSN
https://psn.medical.washington.edu/login.asp
x?ReturnUrl=%2fdefault.aspx
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Patient Safety Net Navigation
Event or Near Miss
Occurs and Event
Entered by Front
Line Reporter
Online Event
Entry
Ancillary Manager
if specific event
type (ie. Falls,
Transfusion
events)
Department
Manager where
event occurred
Immediate Email
notification of new
event is triggered
to:
Pharmacy
Manager (if
Medication Error)
Quality Manager
(All Event Types)
Lab Quality
Manager (If Lab
Event)
Sends consultation
to additional
managers for
feedback if needed
Event Review
NOTE: “Managers” can be
Physicians, Pharmacists, Nurse
Managers, Lab Managers,
The Life of a
PSN Event
Manager
Reviews event,
documents any
follow up, and
submits.
CCP Quality
Manager
(Product Related
Events)
Risk Manager
(High Harm
Scores)
Reviews for
harm severity
and adjust
harm score as
needed
Quality Manager
Does final review of
event and all
manager reviews,
submits event to
UHC.
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Conducts Root
Cause Analysis
as Needed
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Patient Safety Net Navigation
All Submitted Events
Available for review
for each managers
respective area.
Data Reports
Compiled by Quality
for distribution/review
throughout the clinic
Standing Committee
Reviews of specific
event types (ie. Med
Errors, specimen
labelling)
Ad Hoc Reports by
manager request, for
example:
Contrast Reactions
Event “Type” Specific
Reports (ie. Falls)
Dashboards
Monthly
Departmental
Specific Reports
Falls
Apheresis
Apheresis
Patient Safety
Council
Chemo Spills
GenOnc
Transfusion Services
Medication Safety
Infusion
GenOnc
National Patient
Safety Goals
Inpatient Ops
Event Reports
WomCen Imaging
Medical Staff
Womens Center
Pharmacy
Research
Procedure Suite and
IR
Infusion
Mislabeled
Specimen
Environment of Care
Adverse Drug
Reactions
Laboratory Quality
CCP Quality
Alliance Lab
Lab QI
Pharmacy
Radiation Oncology
Proc Suite/ IR
HSCT
Reqing Crew
WomCen
Transfusion Cmt
HSCT
Imaging
Medical Imaging
Blood Irradiation
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Need Help?
For any questions regarding Patient Safety Net,
contact:
Maya Luzzi
Patient Safety Net Onsite Administrator
[email protected]
288-2236