Collaboration around patient safety
Times have changed since the 1980s, when patient safety was “swept under the rug,” said Ronni Solomon, executive vice president and general counsel at The ECRI Institute, at the Bipartisan Policy Center’s Health Innovation Initiative policy forum on Dec. 3.
“People did not talk about safety issues in a proactive way. People did not talk about their problems,” she said.
Now patient safety is a buzz phrase within the industry, as collaboration builds among providers to develop best practices and more organizations participate in reporting programs.
The rise of health IT adds a whole new layer of complexity to patient safety, said Solomon. “We need to be able to collect information on how health IT can have unintended consequences and at the same time we have to take apart systems and determine where health IT can live up to its promise to improve safety.”
The Alliance for Quality Improvement and Patient Safety helps its provider members build a safe healthcare system in a way that removes fear of litigation, according to Peggy Binzer, the center’s executive director.
The patient safety organization (PSO) came about thanks to the Patient Safety and Quality Improvement Act of 2005, which was passed to create a culture of safety by providing legal protection for quality information while permitting the sharing of best practices and other information to continuously improve the quality of patient care. “The culture really promotes transparency, so anyone can raise patient safety issues without penalty,” Binzer said.
Some member providers are working with vendors on specialty projects, and using PSO protections to collect information to discern risk. When health IT systems were first designed, the most important feature for physicians was flexibility but “now we see that too much flexibility is causing problems.” Providers and vendors are increasingly working together on these problems. “I think it’s an exciting time.”
The ECRI Institute has been involved in patient safety reporting since 1971, and since that time has participated in reporting programs of all types: large and small ones; voluntary; and mandatory. “Over the years we’ve seen 3 million adverse events, near-misses and hazards,” she said.
It’s difficult to ascertain how many involve health IT. “We’re been counting on healthcare providers to give us information, but where do they get information? From the frontline. Do nurses really know if health IT was involved?” she said. A medication error might involve CPOE, but it isn’t always obvious. “We’ve got to ferret it out.”
The ECRI Institute launched a multi-stakeholder collaborative to make sense of both the structured and unstructured data they receive on safety incidents. “This is a self-funded partnership, which means everyone is contributing their own time and sweat equity into this,” she said.
The goal is establishing workgroups on very specific issues that have solutions (i.e., cut and paste, too many records open on a desktop) and formulate some best practices at mitigating these threats.
She noted that most often it’s the narrative in a patient safety report that provides the greatest insight into an occurrence, not the drop down boxes. “The reality is you’ve got to see what happened,” she said. However, sometimes the data given are not very rich and detailed, which is challenging.
“We’ve got to take data and translate it into something actionable and meaningful. That’s no small task. At the end of the day, you’ve got to choose something to work on that will make a difference to people,” she said.