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New advances in the war against "never events"

by Loren Bonner , DOTmed News Online Editor
From the November 2012 issue of DOTmed HealthCare Business News magazine

Organizing around patient safety
The Patient Safety and Quality Improvement Act was signed into law in 2005 with the intention of fostering a culture around patient safety. Within the law, Patient Safety Organizations were created so that health care organizations and related groups could share and analyze information related to patient safety events in a protected and educational way. Regulations for PSOs were finalized in 2009 and ECRI Institute became one of the first to sign on.

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“We learn from what everyone is submitting. Rather than keep it within one organization, if you bring it together, you can learn more,” says Barbara Rebold, director of PSO operations at ECRI Institute.

Keeping with that idea, in 2004 Pennsylvania became the first state to require health care providers to report adverse events. The law says that Pennsylvania hospitals must report near misses and serious events via a confidential reporting system. Today’s PSOs are based in large part on this existing system— except for one major caveat: providers report to PSOs on a voluntary basis.

Rebold says the nature of voluntarily reported information has not hindered what can be discovered from the data.

“There’s a lot to learn but it’s not benchmark data, it doesn’t represent everything. But I can tell you that of over 125,000 events in our voluntary [database] and in Pennsylvania’s over 2 million events, we see the highest volume of reports are falls, medication events and pressure ulcers,” she says.

More than 70 groups are certified PSOs—they range from dedicated health care bodies like ECRI Institute’s to small and large hospital systems to software vendors.

As they grow, supporters want to see them become more integrated within health IT to create the most robust information possible. This includes not just electronic health records, but pharmacy ordering, lab systems and radiology systems.

Currently, at least 27 states have laws that require hospital-acquired infections (HAIs) to be reported. In addition, in order to receive Medicare payments, hospitals must track and report medical errors, although a recent report from the Department of Health and Human Services finds hospital employees are actually only reporting medical errors about one in seven times.

Innovating around PSOs
GE Healthcare’s PSO will officially launch what it calls the Global Patient Safety Network commercially in January 2013. It will be available first through the GE PSO and over time to anyone in health care, according to Jeff Terry, general manger of operations solutions development at GE.
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