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“Take a system-wide view of events that may be happening, accelerate decision-making in terms of needed interventions, and support sustainable change over the long term.”

Patient safety activity Purpose of activity

Hospital Common Format Reporting

The concept in the development of the AHRQ Common Formats is that providers would be able to collect information and then conduct performance comparisons based on standardized data elements. As an early adopter of the Common Formants, Clarity PSO has been collecting events using these templates since 2011, which has allowed us to trend data across individual facilities and across the county. Common Format reporting was also allowed for deep dive analysis of safety topics such as patient falls and costs of falls, medication administration and HIT, surgery-related errors

Radiology Misread Analysis Ambulatory Safety Initiative

In-Camera Patient Safety Collaborative

Policy/Procedure Review and Manual Creation

Infection Control Culture of Safety Tool Kit

Analysis of 10s of 1,000s of peer-reviewed final interpretations of radiology imaging: The analysis focused on the topics of (1) stress of reading STAT, (2) provider fatigue, (3) problem-prone modalities such as abdominal CTs.

A study of three data elements in relation to ambulatory care delivery: medical malpractice claims, self-assessment survey and analysis of risk factors, and real-time event reports. Goal is to identify those areas of patient harm and potential errors outside the hospital itself to support a culture of safety across the healthcare continuum.

Education session involving multiple provider types. Discussion of safety concerns occurring in their organizations and the industry. Focused education on how to develop a culture of safety. Our most recent collaborative was in relation to Nursing Peer Review best practices.

Critique and cross-map of policies, procedures and clinical protocols in number of areas such as moderate sedation, falls, medication administration, infection prevention. Identify best practices. Also created PSO safety manual for staff education and guideline.

Analysis and tool development to identify best practices in the prevention as well as surveillance of infections for national dialysis provider.

An assembly of resources and tools to help healthcare providers move deeper into their organizations in raising the awareness of what constitutes patient safety and how safety can be measured to prevent deterioration.

  together to accept data from listed PSOs nationally. Once operational this can become a rich source of information for healthcare providers nationally to reduce harm and enhance healthcare quality.

Healthcare providers working with a PSO have the power to move

from experiencing repeatable (and arguably preventable) errors that eventually cause harm to a more predictive modelling process that can determine where the potential for harm exists and where it can be proactively mitigated. One way that PSOs will help to do this is to transform Common Format reporting from its current state (which is a retrospective analysis of an event) into a surveillance type of analysis.

  look at safety. Yes, we must continue in-depth analysis and research and   infuse safety into every aspect of care delivery from the very beginning of formal education and training as well as those not-so-obvious areas.

Clarity PSO embraces our role as a part of this exciting movement, partnering with providers across the country to continuously foster excellence in patient care and safety in all healthcare delivery settings. 

16 | HEALTHCARE RISK MANAGEMENT REVIEW | Annual 2014 What the PSQIA means for healthcare providers

• Aims to improve safety by addressing: • Fear of malpractice litigation; • Inadequate and varying protections by state laws; and • Inability to aggregate data on a large scale.

• Creates PSOs to assist healthcare providers in their patient safety activities.

• Provides Federal legal privilege, as Patient Safety Work Product,  patient safety and healthcare quality enhancement purposes and assembled and reported by the healthcare providers to a PSO or developed by a PSO to conduct patient safety activities.

• Limits the use of patient safety information in criminal, civil and administrative proceedings and imposes monetary penalties for  

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