patient safety intelligence report bellevue hospital

Why do hospitals survey their staff?

Hospitals regularly survey their physicians, nurses, and other staff on the culture of safety to measure how well staff works together to keep patients safe. Then, hospitals provide feedback on the results to leaders and hospital staff and create plans to improve. Dangerous bed sores. Patient falls and injuries.

How many points do hospitals get for CPOE?

Hospitals can earn up to 100 points for using a well-functioning CPOE system in most areas of the hospital. Timing of the data. What safer hospitals do: Hospitals use CPOE systems in all areas of the hospital and regularly test those systems to ensure they are alerting doctors to potential ordering errors.

What is the hospital team doing before colon surgery?

The hospital team uses appropriate antibiotics before surgery, cleans the skin with a special soap that kills germs, and closely watches patients during and after major colon surgeries. Dangerous object left in patient’s body. Surgical wound splits open. Death from serious treatable complications. Collapsed lung.

How many points can a hospital earn for evaluating nurse staffing levels?

Hospitals can earn up to 100 points for evaluating nurse staffing levels and their relationship to adverse events, holding leadership accountable for adequate and competent nurse staffing levels, providing staff education, and developing implementation plans for effective nurse staffing levels. Timing of the data.

What happens after surgery?

Death from treatable serious complications. Sometimes after surgery, patients can develop serious complications while they are in the hospital. They might catch pneumonia, have a heart attack, or lose function in their kidneys or liver. These problems are serious but can be treated by a good hospital team.

What is patient safety event reporting?

Patient safety event reporting systems are ubiquito us in hospitals and are a mainstay of efforts to detect patient safety events and quality problems. Incident reporting is frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide detailed information. Initial reports often come from the frontline personnel directly involved in an event or the actions leading up to it (e.g., the nurse, pharmacist, or physician caring for a patient when a medication error occurred), rather than management or patient safety professionals. Voluntary event reporting is therefore a passive form of surveillance for near misses or unsafe conditions, in contrast to more active methods of surveillance such as direct observation of providers or chart review using trigger tools. The Patient Safety Primer Detection of Safety Hazards provides a detailed discussion of other methods of identifying errors and latent safety problems.

What is the Patient Safety and Quality Improvement Act?

The legislation provides confidentiality and privilege protections for patient safety information when health care providers work with new expert entities known as Patient Safety Organizations (PSOs). Health care providers may choose to work with a PSO and specify the scope and volume of patient safety information to share with a PSO. Because health care providers can set limits on the ability of PSOs to use and share their information, this system does not follow the pattern of traditional voluntary reporting systems. However, health care providers and PSOs may aggregate patient safety event information on a voluntary basis, and AHRQ will establish a network of patient safety databases that can receive and aggregate nonidentifiable data that are submitted voluntarily. AHRQ has also developed Common Formats —standardized definitions and reporting formats for patient safety events—in order to facilitate aggregation of patient safety information. Since their initial release in 2009, the Common Formats have been updated and expanded to cover a broad range of safety events.

How is event reporting used in health care?

A 2016 article contrasted event reporting in health care with event reporting in other high-risk industries (such as aviation), pointing out that event reporting systems in health care have placed too much emphasis on collecting reports instead of learning from the events that have been reported. Event reporting systems are best used as a way of identifying issues that require further, more detailed investigation. While event reporting utilization can be a marker of a positive safety culture within an organization, organizations should resist the temptation to encourage event reporting without a concrete plan for following up on reported events. A PSNet perspective described a framework for incorporating voluntary event reports into a cohesive plan for improving safety. The framework emphasizes analysis of the events and documenting process improvements arising from event analysis, rather than encouraging event reporting for its own sake.

What is PSNet perspective?

A PSNet perspective described a framework for incorporating voluntary event reports into a cohesive plan for improving safety. The framework emphasizes analysis of the events and documenting process improvements arising from event analysis, rather than encouraging event reporting for its own sake.

Why are event reports limited?

The spectrum of reported events is limited, in part due to the fact that physicians generally do not utilize voluntary event reporting systems.

Is there a voluntary event reporting system?

Voluntary event reporting systems need not be confined to a single hospital or organization. The United Kingdom's National Patient Safety Agency maintains the National Reporting and Learning System, a nationwide voluntary event reporting system, and the MEDMARX voluntary medication error reporting system in the U.S.