1. The New Patient Safety Net How to enter a report

2. Outline What is PSN? Importance of Reporting Who can enter an event Navigating through the reporting tool

3. What is Patient Safety Net (PSN)? The online reporting system used at HMC, SCCA, and UWMC for reporting adverse events or potentially unsafe conditions. The system tracks unsafe conditions, near misses, and errors that can affect the safety of patients, staff, and visitors. These are often referred to as ‘PSN Events’. The system is also used to report staff injuries or blood borne exposures at HMC and UWMC.

4. Some examples of Event Reports : Events: Errors in patient care that reach the patient causing harm or inconvenience can be due to unsafe practice, staff fatigue, distractions etc. Wrong drug administered Specimen not labeled Near Miss: Events that do not reach the patient but have the potential to cause harm if not corrected. RN double checks a medication and realizes the wrong dose was sent from pharmacy. RN sends it back, receives the correct dose, and administers the correct dose to the patient. Unsafe Condition: Environmental factors or processes that have a potential to harm a patient. Tear in carpet that could lead to a fall.

5. Importance of PSN PSN is a vital tracking tool. Without PSN reports it would be difficult to monitor how safe we are and work on improvements where needed. Each report entered is reviewed and followed up on by area managers as well as Patient Safety staff. Events are tracked over time to help identify areas for potential system improvements and monitor the safety of our services.

6. Accessing PSN All staff with an AMC logon have the ability to enter a PSN. PSN is accessed via an icon located on all UW Medicine networked computers.

7. Navigate through PSN by using the tabs at the top of the page. The system will automatically log you out if no keyboard/mouse activity for 30 minutes. A red asterisk * indicates that field is required. You cannot continue until you fill in that information. Helpful Hints

8. General Concepts The intent of PSN is for tracking issues in patient care, not staffing performance. Avoid use of blaming language when entering a PSN. The intent is to identify and track issues, not “finger pointing”.

9. Click on the PSN icon on the desk top to access PSN Navigation of PSN

10. Log In using your AMC account username and password PSN Administrator phone number – available if help needed

11. Select according to the type of event. Search for patient affected by entering H#, U# or last name/first name and clicking Search Tip! Searching by H# or U# is preferred. Searching by name may take an extended amount of time to identify the correct patient.

12. Click “Select” to pick correct patient Click “Refine Search” if needed Patient Look Up Page

13. Confirm you have selected the right patient and then click Next > Patient Look Up Page

14. Select Event type: Identify the category of event. You can click on the folders of each main category to see more choices.

15. Enter the date/time the event was discovered. Enter the date/time of event occurrence.

16. EXAMPLE: You are a lab tech who received a specimen from a unit without a label. Select the unit as the location where event occurred. Your lab is the other location. Enter the location or locations involved in the occurrence.

17. Describe the event including any safety concerns. Provide any recommendations for preventing this event from occurring again. Avoid placing blame, i.e. “RN did a bad job, totally screwed everything up by not labeling specimen. “ Focus instead on how to help prevent this from happening again, i.e. “Specimen labelling was incorrect. Should have included pt name/MRN/etc.”

18. Event Detail page may show additional questions depending on what category you picked. Provide as much information as you are able.

19. Select extent of Harm as a result of the event. You can also click on the harm levels to receive more information on definitions.

20. Who was involved? Provide the names of staff who were involved in the event, or who may be able to give additional information. This is not required.

21. Navigation of PSN You can submit reports anonymously. However, providing your contact information will allow your manager to follow up with you regarding the event. Enter you name and contact information.

22. Final step. Hit Submit.

23. Navigation of PSN If you have multiple events to enter you can add another report easily with this option.

24. Congratulations! You have now submitted an event report. This is the Thank you Screen. Once the “submit” button is hit, an email notification is sent to managers of the area s where the event occurred, as well as to Patient Safety staff,. The review and improvement process begins.