Patient Safety Intelligence 101

What should I report using the PSI System?

Any time something happens and you catch yourself thinking, "that could have been safer...or more timely...or more efficient...or more effective...or more equitable...or more patient/provider-centered" you should report it. Squeaky wheels get the grease, so use the PSI system to direct attention to systems that could be better for our patients and ourselves!

What is the most important information to convey in a PSI?

A brief (executive summary) of the event, the system(s) involved that need further improvement, and anything you can think of that might fix the issue.

What do you mean by Patient Safety Intelligence?

Everything we do in health care is affected by the systems and processes that we use. Some of these are personal processes, like the way we learn to talk to patients. Some are shared on a limited scale, like the process a consulting service uses to orient new trainees to a rotation. Some are shared on a larger scale, like the system we use to document daily patient encounters (EMR - at OHSU, Epic). Regardless of the type of system, all have flaws and eventually, these flaws compromise care in some way (safety, efficiency, value, patient- or provider- experience). In order to raise awareness of, and hopefully get someone to help fix, a flaw in a system, we need a way to broadcast that a system or process needs improvement. At OHSU, we use the Patient Safety Intelligence system for this. The more we report flawed systems, whether or not these flaws have actually harmed patients, the more we can improve our systems and processes of care.

In short - reporting systems that need improvement helps us make our systems, and the care we provide, better for our patients and ourselves.

How does event reporting help improve patient care?

When harmful events and near misses (events with the potential to cause harm that are caught before reaching the patient) occur, or when we catch potentially unsafe or inefficient aspects of a care system, they signal that some part of the healthcare system is not functioning as well as it could. Filing a report (at OHSU, called a PSI) signals to system leaders that the process(es) associated with the error are in need of attention. All reports are reviewed and those that are higher risk or that are clustered around a similar common theme/process are triaged to a more in-depth review & response. In short, reporting errors or sub-optimal systems directs resources to processes in need of fixing so that future care can be improved. 

What is a Culture of Safety?

This refers to our collective attitudes and behaviors as they relate to the safety of our systems and processes of care. It encompasses:

  • Trust that reporting will be praised and handled fairly (Just Culture; requires a clear line between most errors and the minority of unacceptable acts that result from reckless behavior & which may require disciplinary action)
  • Everyone's commitment to report all harmful events and near misses (Reporting Culture)
  • Leadership's commitment to review all error reports (Informed Culture)
  • Institutional commitment to use prior events to shape future system improvement (Learning Culture)

When Should I File a Safety Incident Report?

In short, anytime you feel care has unfolded in an unintended and negative way, you should file a report (though please ensure the patient(s) & staff affected are out of harms way before you report the error)

QUIZ YOURSELF! 

What should you do...(click a scenario to reveal the answer)

When an error occurs and a patient is harmed?

Report it! Let's prevent this from happening again!

When an error occurs but is caught before it reaches the patient (near miss)?

Report it! This is a free lesson! We shouldn't wait until harm is done to improve!

When you suspect a system or process contributed to a negative outcome but are unsure?

Report it! We would rather investigate a false lead than continue to use a faulty system!

When a patient or their support person(s) report a safety concern?

Report it! Everyone should feel empowered to comment on how to make our systems safer!

When someone else on the care team (attending, nurse, pharmacist, scrub tech, etc.) has already filed a PSI?

Report it! Your perspective on both the contributors to the error & possible solutions are valuable!

When you feel a member of the care team has acted unprofessionally?

Talk to a supervisor to see if a PSI would be beneficial! This sounds less like a system/process issue, so the best initial step is ask a supervisor or trusted colleague for their advice regarding the way your program surfaces professionalism issues.

Have a safety situation that you are not sure how to handle? Don't struggle alone - feel free to reach out to the Faculty Lead for the OHSU HQSC, Jake Luty, MD at lutyj@ohsu.edu with questions. 

What happens after I report a safety event or sub-optimal system?

At OHSU, all reports are reviewed by Patient Safety leadership and triaged for further action (feedback to unit supervisors, topic trending, more in-depth analysis & response like a Root Cause Analysis or Healthcare Failure Modes & Effects Analysis). Reports submitted by residents and fellows are also reviewed by the OHSU Housestaff Quality & Safety Council's (HQSC) Patient Safety Sub-Committee and used to generate reports for Programs and Patient Safety Leadership, as well as to inspire improvement initiatives of the HQSC. 

In short, your reports are reviewed and contribute to system improvement, so are worth the effort & greatly appreciated!

Link to read more about OHSU's Event Reporting & Review policy

Where do I go to file a report?

Note: you need to be on a computer connected to the respective health system's network for either link to work. Email lutyj@ohsu.edu if either link is not working. Thank you for reporting!!!

How can I get involved with a patient safety initiative through the OHSU HQSC?

What is OHSU's Policy Regarding Adverse Event Management & Error Disclosure?

Note that you must log in to O2 for these policies to be viewable.