1. Patient Safety Organization orientation for workforce

2. Center for patient safety pso
PATIENT & PROVIDER SAFETY
PROTECT
Protect patient safety and quality work.
PREVENT.
Prevent adverse events and patient harm through supportive cultures.
(Name of agency) has joined a Patient Safety Organization – the Center for Patient Safety located in Jefferson City, MO
Why? To help us improve our patient safety and therefore patient outcomes.
The PSO helps us (review slide) Protect ---- Learn Prevent (from slide)
LEARN
Learn best practices and improvement opportunities.

3. How psos help improve patient SAFETY
Aggregate data and reports from (name of agency)
Providers can work together and learn from mistakes
Non-punitive
Providers receive protections
How do PSOs improve safety?
PSOs aggregate data from many providers to identify risk patterns of care and system failure
Providers can work together in a confidential, protected space to share and learn how to prevent mistakes
PSOs are not a regulatory body – there are no fines or slaps on the wrist. PSOs are here to help.
Participating providers are assured that their safety work will not be used against them.

4. A federal law is AVAILABLE
Patient Safety and Quality Improvement Act of 2005
(42 U.S. Code Part C - Patient Safety Improvement)
Framework that encourages adverse event reporting
Makes PSO reporting safe by providing federal protection
Provides environment for safe and confidential sharing, learning and prevention
What does that mean?
There’s a federal law that encourages medical event and near miss reporting so we can learn from each other and prevent errors.
The law provides protection for patient safety and quality information so it cannot be used against us in a lawsuit
More importantly, it provides an opportunity to safety share with one another and learn from others’ errors – thus having a positive impact on our patient outcomes

5. PSO HOW PSOs WORK PSO COLLECTS DATA DATA IS ANALYZED
LESSONS ARE SHARED
Best Practices
Alerts/Watches
Resources/Toolkits
Newsletters
Webinars
Conferences/Meetings
PSO
TYPES OF EVENTS COLLECTED:
ADVERSE EVENTS
NEAR MISSES
UNSAFE CONDITIONS
Air Medical Service
EMS
Fire Based EMS
Hospital Based
On the right, PSOs collect events such as medical errors or near misses and they are entered into an on-line database
Then in the middle of this graph the PSO then analyzes the data and reports back to the PSO participants via best practices, lessons learned, Safety Watches. Safety Alerts, patient safety resources, newsletters, webinars and conferences for its members
On the right is the list of types of agencies and bases that can get the information to improve patient safety
Private Ambulance Svc
PUM

6. EMPLOYEE RESPONSIBILITIES
Report medical errors, near misses and unsafe conditions per (name of agency’s) policy
Keep information confidential – use only within (name of agency) to improve patient safety
Commit to improving patient safety to ultimately improve patient care
All employees are expected to report near misses, medical errors and unsafe conditions per agency’s policy
Patient safety information is much like HIPPA – the federal law protects the information and it can be used only within the agency to improve patient safety. There are civil fines for breaches.
Most important – each and every leader and crew member commits to do everything possible to improve patient safety – as it ultimately means we provide better patient care and have better outcomes.

7. What to report
Medical Event (Incident) – A patient safety event that reached the patient, whether or not the patient was harmed
Near Miss: A patient safety event that did not reach the patient
Unsafe Condition: Any circumstance that increases the probability of a patient safety event

8. What to report - Examples
Airway Management
Esophageal Intubations
Dislodged devices
Difficult airways
Cricothyrotomy or other high risk airway events
Ambulance Crashes
Crash or almost crashes - What factors played a role in the crash?  Dangerous road, fatigue, distractions

9. What to report - examples
Device/Medical Supply
Stretcher failures - Battery failed or other mechanical failure
Stretcher tips or collapses
IV pumps, cardiac monitor or ventilator failure
Incorrect equipment or medication ordered or stocked on ambulance
Lost or missing equipment
Medication/Other Substance
Medication mistakes - violation of the 5 rights for med administration 
Exposing a patient to known sensitivity or allergy-latex
Expired medications
Incorrect calculations (i.e. for bariatrics or peds)

10. What to report - examples
 Other
Protocols not followed
Behavioral Health
Harm to crew or patient - violence to EMS crew, patient jumping from ambulance
Extended transports or resource utilization,  extended wait times
Bariatric Patients
Harm to patient or crew during handling
Dispatch Error
Sent to the wrong address or given information that places patient or crew in harm’s way.
Vehicle Incidents
Lost keys - can’t start the ambulance and respond to a call

11. Why report?
Decreased fear in reporting medical errors, near misses and unsafe conditions
Opportunity to learn from others within (name of agency)
Opportunity to learn from other agencies across the nation
Ultimately provide safer care, resulting in improved patient outcomes

12. QUESTIONS OR ASSISTANCE
(Enter Agency PSO contact information):
Center for Patient Safety
Insert agency’s contact person
Contact Center for Patient Safety for assistance