# Presentation: 426579

## Patient Safety Surveillance and Improvement System

**Patient Safety Surveillance and Improvement System**

*Presenter**	**	**Dixie Henry, JD*
*	**	**Assistant Attorney General*
- Date		February 2, 2007

## Vermont Patient Safety Program (PSP)

- Authorizing legislation passed 2006
- Effective July 1, 2006
-  Mandatory reporting of Intentional Unsafe Acts
- Effective following promulgation of implementing rules (est. June 30, 2007)
- Mandatory reporting of “Never Events”
- Mandatory hospital policies and procedures for other adverse events and near misses

## PSP Culture of Safety

- Focus of VT PSP to foster culture of safety within each hospital in VT
- All adverse events and near misses reported, identified, analyzed and corrective action taken within hospital
- PSP:
- Mandatory reports
- Confirms compliance
- Provides technical assistance

## Adverse Event Data under PSP

- Reported to PSP
- “Never Events”
- Intentional Unsafe Acts
- Hospital Internal Reports
- Adverse Events
- Near Misses
- Causal Analyses
- Corrective Action Plans

## Slide 5

## Examples of Adverse Events

- “Never Event” (report to PSP)
- Surgery performed on wrong body part
- Other adverse event (not reportable to PSP)
- Patient fall, bruised but no death or serious disability
- Near Miss (not reportable to PSP)
- Almost administered wrong medication, but error recognized and error averted

## Mandatory Reporting of “Never Events”

- National Quality Forum list of “Never Events”
- Hospital must:
- Report all “Never Events” to PSP
- Conduct causal analysis
- Develop corrective action plan

## Internal Hospital Adverse Event Surveillance and Reports

- Reports to PSP not required for other adverse events and near misses
- Hospital internal procedures must:
- Identify, track, and analyze all adverse events and near misses
- Conduct causal analyses of all adverse events and near misses
- Develop corrective action plans
- Disclose to patients or family adverse events that cause death or serious bodily injury

## Mandatory Reporting of Intentional Unsafe Acts

- Based on VA System
- Report within 7 days after discovery
- Adverse event or near miss results from:
- A criminal act;
- A purposefully unsafe act;
- Alcohol or substance abuse; or
- Patient abuse
- PSP must notify relevant licensing, regulatory and law enforcement authorities

## Anticipated Electronic Systems	

- PSP may permit hospitals to file “Never Event” and Intentional Unsafe Act reports electronically
- PSP electronic system to aggregate data
- Hospitals may use electronic systems for:
- Internal reporting
- Identifying and tracking adverse events

## PSP Access to Hospital Data

- “Never Event” and Intentional Unsafe Act data reported directly to PSP:
- Incident Report
- Causal Analysis
- Corrective Action Plan
- Peer Review
- Other adverse event and near miss data not reported to PSP:
- PSP periodic on-site review of internal reports, causal analyses, corrective action plans, peer review materials
- Purpose: Compliance oversight and technical assistance

## PSP – Use of Data 

- Aggregate and analyze data
- Develop and implement strategies to target specific adverse events
- Verify hospital compliance with:
- PSP requirements
- Internal policies and procedures

## Barriers to Use of Hospital Data

- Confidentiality
- All information made available from providers to PSP is confidential
*Exception is for Intentional Unsafe Acts*
- Within PSP, access to peer review information limited to individuals responsible for verifying compliance with PSP requirements
*Exception is for enforcement purposes *

## Public Access to Provider Data

- Anticipate 2 years after implementation, some adverse event data may be included in hospital community reports

## Vermont Patient Safety Surveillance and Improvement System 

- 18 V.S.A. Ch. 43A
- http://www.leg.state.vt.us/statutes/fullchapter.cfm?Title=18&Chapter=043A