Reducing medical errors with enhanced patient safety reporting
The dangers of medical errors are prevalent in any hospital encounter, both military and civilian. Today, health care experts estimate that one in 10 patients suffers from a medication or non-medication related event while hospitalized.
To combat those dangers and minimize a patient’s risk, the Military Health System is developing a web-based, anonymous, electronic reporting of patient safety events.
Currently, MHS uses a paper-based system for reporting patient safety events. When fully deployed later this year, PSR will deliver standardized, electronic event reporting for Department of Defense direct care facilities worldwide. The analytic tools in PSR identify areas for patient safety and quality improvement initiatives to reduce the frequency and severity of medical safety events. The system is secure, confidential and easily accessible online.
The plan calls for all military treatment facility staff with a Common Access Card to use the PSR to report medication and non-medication related events resulting in a consolidated, streamlined event monitoring system. Staff will use PSR to report any safety-related issues such as near misses - events or situations that could result in harm such as an unmarked wet floor or a poorly lit hallway; adverse events, or situations that cause unexpected harm to a patient, employee or visitor; or “sentinel events,” or circumstances causing death, physical injury or psychological injury to a patient, employee or visitor.
The PSR tool was built by MHS using a commercial-off-the-shelf product that was successfully used throughout the United Kingdom and Canada. Typically, patient safety reporting initially drops at facilities using this system as the user transitions from paper to Web-based reporting. Within about 90 days, however, patient safety reporting usually soars for several months before dipping again. The key reason is usually because staff members using PSR are identifying more near misses sooner and helping to prevent serious injury from occurring in the future.
The implementation of PSR across the Army, Navy and Air Force will enable standardized reporting of both medication and non-medication patient safety events in the MHS. This allows the MHS to improve data collection, streamline processes, track errors and more effectively analyze the captured data. As a result the MHS can offer faster and more accurate alerts of safety events to potentially save lives. In addition, the standardized web interface will improve data accuracy, increase data security and reduce paper consumption in the military treatment facilities.
“Patient safety is everyone’s business and by using PSR,” said Defense Health Services Systems Deputy Director of Clinical Support, U.S. Public Health Service Cmdr. Donald Sawyer. “The MHS is promoting the steps required to proactively improve patient safety. Using PSR will provide the MHS a greater ability to learn and share safety information by standardizing data capture and taxonomy and centralizing the capture, collection and aggregation of event level data.”
Limited deployment of PSR and system acceptance testing began at the following sites in April: Fort Meade, Md.; Fort Benning, Ga.; Madigan Army Medical Center, Wash.; National Naval Medical Center, Bethesda, Md.; Naval Hospital Camp Lejeune, N.C.; Naval Hospital Pensacola, Fla.; Andrews Air Force Base, Md.; Wilford Hall Medical Center, Texas and Davis-Monthan Air Force Base, Ariz. Independent testers will visit the sites after approximately 90 days of LD and SAT to acquire user feedback. The testers will balance system requirements with user wants and needs, determining if the system works not only in the lab, but also in the field.
Once testing is complete in late 2010, the system will begin deployment at approximately 600 MHS direct care facilities worldwide.
The PSR initiative is driven by the MHS Office of the Chief Information Officer Defense Health Services Systems program office and was created in May 2008.
Jenna Noble, Defense Health Services Systems
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