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PA-PSRS User Manual - PA

1. 161 SELECTED PROGRAM MEMORANDA ccor duce eaten i ehe eee mra dne pa ox a enhn ae Re doe a t tn etn ev eo eme os 162 PROGRAM MEMORANDUM No 2015 02 INTERPRETATION OF THE DEFINITION OF SERIOUS 162 EVENTS USED BY THE PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM ANALYSTS 162 UPDATED SINCE THE RELEASE OF THE AUTHORITY S FINAL GUIDANCE FOR ACUTE HEALTHCARE 162 FACILITIES DETERMINATION OF REPORTING REQUIREMENTS UNDER THE MEDICAL CARE AND 162 REDUCTION OF ERROR MCARE SEPTEMBER 27 2014 sese 162 evi 2x ces a san a oe 162 The Definition of Serious Events by the MCARE AGE o eerte tuo EE eai 163 PA PSRS Interpretations of Terms Used in the Serious Event Definition esses entente nnn nnns 166 TOC Ue AO erede tene EN E tide scritte ecrire eris aci ld dieu e otis dne beiden dt 170 Distinction between Serious Events and Adverse Event c cccccccscsssssssssessessesscsscsscsseesessscescsscssseseesessesseseeeesessensesaesaeeseeeeesseeeseaees 170 PROGRAM MEMORANDUM No 2013 07 PA PSRS SECURITY UPDATE FACILITY CONTACT FORM 173 Contact C hange Onn Ss aodio sense eese On ooi AE E de fie ipee M ofi edits See 173 PROCESS COMES Ie ONAN eiecit mac LA M MEI I LIE IU uM ESL PULL IEEE 175
2. Click on a green checkmark or a red X in the complete column to see a detailed report of all entries for the month shown below id ah of 2 b bi 100 zl Facility Inpatient Patient Patient Year Month Cara Ark Outpatient Care Area Name Care Area Type Falls Tracking Group a rina 2012 May Facility 1234 45678 2012 May Care Area Inpatient CCU Cardiac ICU Critical Care 36 2012 May Care Area Inpatient Med General Medicine Ward General Medical Surgical Units 82 2012 May Care Area Inpatient MICU Medical ICU Critical Care 15 2012 May Care Area Inpatient ONCOLOGY Medical Oncology Unit Specialty Units 52 2012 May Care Area Inpatient Newborn Nursery Newborn Nursery Unit Pediatric Care 5 This report can be used to identify care areas with missing data or with zeros entered Click on the ind icon to export this report in Microsoft Excel Word or PDF format Refer to Chapter 6 Data Analysis for further instructions on exporting data and reports VERSION 6 5 122 JUNE 2015
3. 1d Harrishurg Locations 2 LockHaven Northern Facilities 3 4 Og Ane surgery Center S Wrest Shore Facilities Falls Reporting Program Enrollment Please read Chapter 8 Falls Reporting Program for complete instructions for enrollment and a detailed explanation of the program VERSION 6 5 19 JUNE 2015 Event Reports oubmitting new reports and searching amending submitted reports Reportable Events What is a reportable event The PA PSRS Program is designed to collect reports on four basic types of events Serious Events are events occurrences or situations involving the clinical care of a patient in a medical facility that either a results in death or b compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient Incidents are events occurrences or situations involving the clinical care of a patient in a medical facility which could have injured the patient but neither a cause an unanticipated injury nor b require the delivery of additional health care services to the patient Infrastructure Failures are a undesirable or unintended events occurrences or situations that affect the infrastructure i e physical plant and service delivery systems of a medical facility or b the discontinuation or significant disruption of a service which could seriously compromise patient safety Other events are those which CMS requires
4. If the Reset button is selected before pressing the Save button any currently entered data will not be saved To close the utilization data screen click the Close button which will prompt the user to save the data if there are changes and then close the screen Amending Facility level Utilization Data Participating hospitals have the ability to amend their Utilization Data for the previous 3 months To amend utilization data return to the Navigational Bar screen where you will see a drop down box with menu choices Select Edit Utilization Data from the Utilization Data menu Utilization Data e Enter New Utilization Data Edit Utilization Data Ve LEE CAA E G The amending utilization data screen will be the same as the data entry utilization data screen except there will be drop down menus for the year and month Data for the most recent month will be displayed To edit data for a different month select the month for the data to be modified from the drop down menus The amending utilization data screen will be the same as the data entry utilization data screen except there will be drop down menus for the year and month Data for the most recent month will be displayed To edit data for a different month select the month for the data to be modified from the drop down menus VERSION 6 5 102 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Enter
5. PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Utilization Data Entry Unit Level Utilization Data Entry When the Utilization Data menu option is selected a screen titled Enter Unit level Utilization Data for Month Year will be displayed Enter Unit Level Utilization Data for January 2012 Inpatient Care Area Inpatient Care Unit Surgical Services Unit Level Patient Days Subtotal Patient Days from Other Unit Total Facility Level Patient Days Outpatient Care Area Occupational Therapy Outpatient Clinic Physical Therapy Radiology Total Patient Encounters Definitions Help Care Area Type Med Surg Pediatric Unit Surgical Unit Patient Days Ley Care Area Type Rehab Occ Therapy P Pediatric Clinic Rehab Phys Therapy Patient Encounters Imaging Combined Services The unit level utilization data entry screen has two tables The top table is for reporting inpatient utilization data patient days The bottom table is for reporting outpatient utilization patient encounters Both tables have three columns The first two columns are titled Care Areas and Care Area VERSION 6 5 Types Care areas are inpatient and outpatient units as defined by your institution The care area type column consists of general PA PSRS category unit designations e g medical surgical intermediary unit inpatient psychiatric assigned to each
6. Technical factors Refers to physical items such as equipment physical installations Management priorities software materials labels and forms External Technical failures beyond the control and responsibility of the investigating TEX organization Design Failures due to poor design of equipment software labels or forms Construction Correct design was not followed accurately during construction Materials Material defects not classified under TD or TC Organizational factors Refers to the context of the workplace such as SOPs culture and management External Failures at an organizational level beyond the control and responsibility of the investigating organization Failures resulting from inadequate measures taken to ensure that Situational or domain specific knowledge or information are transferred to all new or inexperienced staff Failures related to the quality and availability of protocols with the department too complicated inaccurate unrealistic absent or poorly presented Internal management decisions in which safety is relegated to an inferior position in the face of conflicting demands or objectives This is a conflict between production needs and safety e g decisions about staffing levels Culture Failures resulting from collective approach to risk and attendant modes of O behavior in the investigating organization Active errors human Errors or failures resulting from human behavior Extern
7. CL z e 4 lads m ee ey ti ti ri Uma rama me mr aaa x o gg L Emergency _ _Outpatient_ L Radiology _ Rehabilitation Department Clin Sernices Services E Facility Falls RateforInpatients mg Peer Group PeriodicFall Rate for Inpatients MS Facility Falls Rate for Outpatient S Peer Group PeriodicF all Rate for Outpatients Falls Utilization Data Report Falls Utilization Data Summary This report provides facilities with a summary of the utilization data entered by month The only criteria required for this report is the facility name The Additional Criteria link on the report selection screen is disabled For facility level enrolled hospitals the only column displaying data will be the facility total patient days column For unit level enrolled hospitals data is displayed in both the patient days and patient encounters columns If all data has been entered a green checkmark appears in the complete column If data is missing a red X is displayed see below VERSION 6 5 121 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Falls Utilization Data Summary November 16 2012 Patient Days Patient Encounters Facility Care Changed Care Changed Year Total Area from Area from Complete Total Prev Total Prev Month Month el os ow we lo elm mom lim mpm D D L I LI LX el I X Click on the complete symbol for the month s details
8. Chapter 4 VERSION 6 5 93 JUNE 2015 Chapter Falls Reporting Program Enrollment data entry and using report functions Program Overview The Falls Reporting Program is available to HOSPITALS ONLY Participating hospitals agree to standardize their facility s definitions and reporting of falls and to provide monthly utilization data through PA PSRS This will allow for unit level and or facility level detailed reports of the rates of falls and falls with harm as well as statewide benchmarking Program Enrollment The Facility System Manager is responsible for enrolling in the Falls Reporting Program When the Facility System Manager logs in to PA PSRS the blue horizontal Navigation Bar will appear as below ser Rito Imm To access the Falls Reporting Enrollment screen select Falls Program from the Navigation bar See below At the top of the screen there is a link to the Program Memorandum Click on this link to read a more thorough description of the program what the benefits and responsibilities are for participating hospitals including definitions to be adopted uain page User Administration Care Areas Fale Prooram Resources f toor NN Enrolment Options Definitions Choose one of the falls program options ra The current enrollment status is selected below memg Unit Level Monthly Data Yes agree to standardize my facility s definitions and reporting of falls and to provide monthly u
9. E Error related to Procedure Treatment Test v Regenerate Report Select New Criteria Choose New Report Return to Main Page Harm Score Definitions PA PS fatewide Aggregat PSRS Statewide Aggregate Distribution of Sub Categories Related tc Harm Score Distribution Related to E Error related to Procedure Treatment Test Harm Score Definitions VERSION 6 5 80 DATA ANALYSIS JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Top 3 Event Types by Care Area VERSION 6 5 This report presents a series of three tables that correspond with the three most frequently reported event types in your facility For each of these event types these tables will show you where in your facility by care area they are most frequently reported By selecting Additional Criteria you can modify the report by report type event date gender or age of affected patients PA Pennsylvania Patient Safety PSRS Top 3 Event Types by Care Areas I Wednesday September 14 20605 Reporting System Organization Training Facili Help Selection Criteria Report Submission Type Serious Event Incident v Infrastructure Failure Event Date Current Year Gender All Age All Regenerate Report Select New Criteria Choose New Report Return to Main Page s Physical
10. GoTo Repons Selection Page Retum to Main Page VERSION 6 5 109 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM The screenshot below shows the configurable options for unit level enrolled hospitals Criteria Tor Falls Rates Report Inpatient Care Areas 1 Report Submission Type inciden Falls reports default to Falls with Harm Serious Events only To see all Falls select incident 2 Indieeidinal Vai Data Include all Falls Tracking Groups oruncheck to salect ome specific Falls Tracking Group Falls Tracking Groapa 3 Comparison Group Peer Goup Falls Rate 4 Report Pamat 5 Pericdicity 9 Morti COuarterhy Yearly B Time Frame From Mani Jul i Year 2012 l TeMonhv Jul e Year 2012 7 GoTo Reports Selection Page Return to Main Page Benchmarking Benchmark falls rates will vary based on comparison group and time period selected The system will include hospitals or units within a hospital in the comparison group falls rate calculation on a monthly basis when non zero utilization data is entered for the care areas Comparison group falls rates are calculated for each individual time period when a minimum of five hospitals with complete utilization data for the falls rates is available The State Group includes all facilities enrolled in the falls reporting program that have entered non zero utilization data VERSION 6 5 110 JUNE 2015
11. LocaBon Where Brent Occurred amp Gaile Of Admission Or Date Cf Ambulatory Encounter Date mmiddyrni ail 6a Patent Status Inp ateni Qutpatent Unknown Definitions T Even Dais And Time Cate merda t il Tiree hhii Time Unknown Fa Confirmation Date m Dale immi Tb W ou Are Submifting This Report Hore Than 24 Hours Aller Conirmabon Please Explain maximum 500 characters amp Event Type other specify maximum 250 characters Evert Type Laval 1 Select Event Type a Sut Category Levee 2 T D d il fan Cabmpo s Lane 3 ther ppt HextPage Top of Page Cancel Return to Questions 1 4 ribera guter soi ee ee onder alice te bed Facer bee pag ahallcehy Dir uiae es cies i preceding wi Pe dtu Lie Di E 2004 Peete Patient Salary Aua Ali nghi served VERSION 6 5 26 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Helpful Tip When filling out an event report you can move back and forth through the screens by using the hyperlinks at the bottom right hand corner of the screen For example after filling out the questions on the screen above you can go back to previously completed parts of the form by clicking on the question numbers to which you want to return e Question 6a has three patient status choices To understand the definitions for patient status select the Definitions link located to the right of the field choices When selected a pop up window with
12. PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM The Peer Group includes all facilities enrolled in the falls reporting program that have entered non zero utilization data and that are of similar hospital type see below Acute Care Hospitals are separated into four peer groups based on bed size 0 100 beds 101 200 beds 201 300 beds gt 300 beds Specialty Hospitals are separated into five peer groups based on specialty Behavioral Health Critical Access Long Term Acute Care Pediatric Rehabilitation Both State and Peer Group rates can be calculated and displayed as periodic and aggregate rates see the Falls Rates Reports section below for examples e The peer state periodic falls rate information will provide benchmarking falls rates that fluctuate with each time period e The peer state aggregate falls rates information provides the average single falls rate for the time period selected and is constant over time Falls Rates Reports Facility level enrollment Hospitals enrolled at the facility level will have one falls rates report selection Falls Rates Facility Report This report selection will provide two facility level falls rates reports falls per 1 000 patient days and falls with harm per 1 000 patient days The default report see below will display the most recent month for which utilization data has been entered There is no comparison group VERSIO
13. and discusses the scope of PA PSRS Chapter 2 Getting Started briefly outlines the major functions of the system and teaches you how to log on and navigate PA PSRS Chapter 3 Facility Management provides instructions for the Facility System Manager to perform their required activities Chapter 4 Event Reports teaches you how to enter new reports locate and amend submitted reports and review report status Chapter 5 Report Coding introduces several taxonomies or classification schemes used in PA PSRS and teaches you how your coding of reports affects the usefulness of the data you can output from the system Chapter 6 Data Analysis teaches you how to work with your facility s data to generate meaningful reports to inform your patient safety and quality improvement activities This chapter teaches you how to formulate and run data queries as well as how to produce and save data tables and graphs Chapter 7 Communications explains where to turn for technical assistance provides necessary contact information and discusses other types of communications you may receive from the Authority or its contractors Chapter 8 Falls Reporting Program explains how to enroll in the hospital falls reporting program collect detailed information related to falls enter utilization data and generate meaningful reports designed to assess the effectiveness of and enhance hospital fall prevention programs while benchmarking falls and falls with harm
14. maximum 250 characters Next Page Top of Page Cancel Return to Questions 1 4 5 8 Event Details 9 13 VERSION 6 5 32 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Exhibit 4 1 Elements of a Good Narrative Question 9 asks you to Describe the event Please provide as much detail as necessary in your narrative description to convey the clinical context for the case In describing the case include the following elements if known and applicable Critical elements Example Patient Fall Who GENERIC patient descriptor Post op surgical patient What event Was discovered on the floor of her room Who GENERIC provider roles byanurses aide Where type of site on general med surg floor When in context Six hours after leaving recovery following a scheduled hysterectomy How in context Patient reported she was attempting to get to the bathroom Recovery attempts opportunities The bedrails were up Why Possible explanations include dehydration vertigo from anesthesia or overuse of patient controlled analgesia Include only generic descriptors of persons and places Never include identifying information Other elements to include are Relevant diagnoses Indication s for admission or ambulatory encounter Relevant comorbidities or risk factors Procedures involved Question 14 asks for Recommendations for system improveme
15. this chapter together Each facility should decide e Who will be granted access to the system within the organization and e What care areas and care area groups are relevant to their facility Ideally this should be done before you submit your first report to PA PSRS User Administration VERSION 6 5 From the Main Page when logged in as the Facility System Manager click on User Administration to add a new user or to view edit an existing user s profile When a new facility is created in PA PSRS two sets of User IDs and passwords are created one for the Facility System Manager and one for a PA PSRS User for the facility s legal Patient Safety Officer Before ever accessing the system these two roles will be established for you 14 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FACILITY MANAGEMENT VERSION 6 5 The first thing to do is to edit the profiles of these users to ensure that contact information and other details are correct Next decide whether your facility wants more than one person to have the ability to submit reports to PA PSRS If you choose to allow anyone other than the PSO to submit reports to the system the PSO must ultimately be responsible for the integrity of submitted reports If the PSO wishes to authorize other individuals to submit and amend reports on his or her behalf you may add additional users by following these steps 1 Click User Admi
16. 5 72 JUNE 2015 Chapter 6 Data Analysis Introduction PA PSRS allows you to analyze data from your own facility Using this analytical feature you can e Generate data tables from your own facility s submitted reports e Produce pie charts and graphs that track the number and types of reports submitted by your facility over time in different categories e g by harm score by event type etc e Query the database to look for patterns or trends e Download data tables and graphics for use in presentations and reports to your Board your Patient Safety Committee or others You will not be able to view specific information related to individual facilities and other facilities will not be able to view your facility s reports or data In some cases you will be able to compare your facility s experience with other facilities but only using aggregate de identified data You can also download your facility s data from PA PSRS and import it to a database or spreadsheet application to perform custom analyses on your own Refer to the Standard Data Export and Advanced Data Export topics at the end of this section VERSION 6 5 73 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Accessing Available Reports To access available reports select Analytical Data Tools from the menu bar then select Event Report Data Analysis This will take you to the
17. 7a and 7b click on the calendar icon to get a pop up calendar that can help you answer these questions Note that question 6 permits the response Not Applicable and that Question 7 includes sub questions 7a date the event was confirmed and 7b explanation for any reports submitted more than 24 hours after confirmation Question 8 asks you to identify the event type using the taxonomy for Infrastructure Failures See Appendix B for more detailed information about the Event Type list To choose the event type position your cursor over the words Point here This will bring up a tiered menu of possible selections If you select Other as the event type you must type in a brief description of the event up to 250 characters in the dialog box to the right labeled Other specify Click Next Page when finished to proceed to the next screen PA Pennsylvania Patient Safety Friday February 24 2012 PSRS Reporting System Time remaining ETT Reset Timer Help 7 Event Report amp Locatian Where Brent Occured amp Gale Ot Admission Or Cate Cd Ambulatory Encounter Liate memnidde enn k aE 5a Paliend Stalus Inp atenl Outpatent Linkn cwn Definitions T Event Cate And Time Dale trendy hk aT Tit hhii Time Unknown ra Confirmation Date a Dale mrmiddyyryyk Tb H You Ane Submiffing This Report lore Than 24 Hours Aller Conlirmabon Please Explain maximum 500 characters amp Even Type other spect maximum 250 charac
18. Add another Event Report Return to Main Page s Logoff VERSION 6 5 38 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Report Submission Infrastructure Failure Submitting Infrastructure Failure reports follows the same format as the submission of Incident and Serious Event reports You must be logged onto the system as a PA PSRS User as opposed to the Facility System Manager and Read Only User Pay attention to the screens as they are NOT identical to the screens for Incidents and Serious Events RESPONSES ARE REQUIRED FOR ALL QUESTIONS though Not Applicable is an acceptable response for certain questions There are no event detail questions associated with reports of Infrastructure Failures Screen 1 e Select Infrastructure Failure by checking the box next to this report type Click Definitions for help identifying the report type e Click Next Page to proceed to the next screen gt ne Nednesday January 21 2015 fi Pennsylvania Patient Safety Time remaining KIHIN PSRS Reporting System Reset Timer Help Event Report 1 Report Submission Type Choose only one Definitons Senous Event nie ient v Infrastructure Failure Other Next Page Cancel VERSION 6 5 39 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Screen 2 Questions 1 through 4 e Answer each question by selecting th
19. Facility Level Utilization Data for January 2012 Definitions Help Or Select the Month to Edit January 2012 iv Facility Level Data Patient Days Total Facility Level Patient Days EZ EJ LIC co Submitting Falls Reports Refer to Chapter 4 Event Reports for instructions and frequently asked questions applicable to all event reporting The following information applies specifically to falls reporting Patient Status For HOSPITALS Regardless of enrollment status the system provides a mandatory data field on the first page of the Serious Event Incident Infrastructure Failure PA PSRS report entry form labeled Patient Status Event Report amp Location Where Event Occurred iReauired T 6 Date Of Admission Or Date Of Ambulatory Encounter Required Date mm dd yyyy To 6a Patient Status Required Inpatient Outpatient Unknown Definitions VERSION 6 5 103 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM VERSION 6 5 To understand the definitions for patient status select the Definitions link located to the right of the field choices When selected a pop up window with the patient status definitions will appear on the screen To close this pop up window select the close link Definitiona Inpatient Any admitted patient including observational patients that receive care in a hosptal unit e g med surg unit critical care
20. GUIDE DATA ANALYSIS Saving Analytical Reports PA PSRS supports saving the graphs or tables from any report you generate using the system You can then paste these graphs and tables into word processing documents use them in reports you make to your facility s Patient Safety Committee or to support your own analyses To save a graph or chart select File in the gray toolbar at the top of the image you want to save then select Save Chart This will open a Save as dialog box where you must select a filename and file type To save files for use in word processing applications we recommend saving the chart as a Windows metafile To do this from the Save as dialog box click on Save as type then choose metafile from the menu This will save the document in a form that can be read by most Windows applications To save data tables use your mouse to highlight all the rows and columns of the table you want to save When the area you wish to capture is highlighted press CTRL C on your keyboard to copy Next open a new blank file in your word processing or spreadsheet program and press CTRL V on your keyboard to paste VERSION 6 5 86 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Searching Reports PA PSRS includes a search facility that lets you identify all submitted reports matching a variety of criteria you may set and modify To access the sea
21. MWelinidenus Contact Us Internet PA PSRS Help Desk E Mail Support papsrs pa gqov PAS ET PA PSRS Telephone 866 316 1070 toll free b Explorer To log on to the system you will need your User ID and password which is assigned by either the Patient Safety Authority or the Facility System Manager Log on Steps 1 From the PA PSRS Home Page enter your User ID and Password in the appropriate dialog boxes 2 Press the button marked Click here to Login This will bring you to the Main Menu where you will be able to perform several different functions You can also bypass the Main Menu by checking a box to go directly to the reporting form if you want to submit a new event report VERSION 6 5 9 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE GETTING STARTED Once you log onto the system the screen you see will depend on whether you have logged in as a PA PSRS User Read Only PA PSRS User or the Facility System Manager see User Roles above If you have logged on as a PA PSRS User or Read Only PA PSRS User you will go directly to the PA PSRS User Main Page see below The main page lists all the reports your facility has submitted PA 2 Pennsylvania Patient Safety ti aUne PSRS Reporting System Organization Training Facili Help Event Report Bank Fors Aaa Data Tel Date Range 06 16 2005 to 09 14 2005 new date range Showing 1 20 of 176 Total Records Selected R
22. O A Circumstances that ceuld cause adverse events 6 9 look alike medications confusing equipment etc L B1 An event accumed but raid mH reach tive individual near miss or close call because of chance alone L Bz An event accunmmed but iaki mol reach tive individual Crear miss or close call because of active recovery efforts Dy Cor egieers a C An event occurred matredaehed the indiedua 50 did not care harm and did nel require increased monitidimg an error or omis sion such de a rnissed medicalion dose goes reach Th ngridual E D An event accured 231 requires manito ima t0 conim thal if rested im neo Tar and or requie internsention to pi even Ia rr Event Haan E E An event occumed that contributed to or resulted fn lene any harm and requiredtreatment or interveritiedi F An event occurred that contributed to or resulted in temporary harm and feu ed initial os prelonged hoop sz ated E i An eventi occurred thal contribuled io or resulted in permanent harm LI H An evenit occured hal resuked in a near deaf ee e g required IL care or other intervention necessary o sustain life Ever deonh O L n event occurred Pal contributed a or resulted in death Note Modified frm Nalblonal Cocndneting Council far Mec atop Error Peducpon amd Prevention ACHE Ay 11 Likeihood Of Event Recurrence v Definitions 12 Seventy Of Emtec Resulting From Recurrence Of Evert hail De fi nitions Next Page Top of Page Cancel Retum to Questions
23. Plant Utilities Service Disruption T Administration Management Care Area Name m pai Care Area Name mu Reports Reports 4 T4 T4 aj T4 T T4 E 1 8 1 1 3 1 l 1 8 Test Care Area 25 1 3 1 3 West j 27 3 Test Care Area 26 1 H 1 Total 5 45 5 Total 3 27 3 V Criminal Potentially Criminal or legal Activity All Other Events Care Area Name m of Total Care Area Name m Ue Reports Reports ec mc LOb T T4 a co T T T4 Test Care Area 18 i 1 4 1 Test Care Area 11 o 2o 15 2 Total 1 9 1 Total 2 18 2 Select New Criteria Choose Mew Report Return to Main Page 81 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS High Alert Medications and Steps in the Medication Process VERSION 6 5 This report presents either as a series of pie charts or tables the distribution of high alert medications e g warfarin IV potassium etc associated with submitted medication error reports and also the distribution of steps in the medication process e g prescribing administration etc associated with all medication error reports From the main report selection page you can select report type Serious Event and or Incident By selecting Additional Criteria you can modify the report by event date or by gender or age of affected patients PA 3 Pennsylvania Patient Safety Wadriasday September 14 2005 PSRS Reporting System Organization Training Facili High Alert
24. an ongoing basis Supervision of Processes in place ta monitor staff s performance and actions taken to hold staff staff accountable for their performance Process the medical staff uses to assure that a LIP with clinical privileges supervises each participant in a professional graduate education program in patient care responsibilities Communication The process of relaying information between hospital and patientiramily that with patient family the patientifamily needs to be involved in all aspects oftheir care and care decisions This includes patient family education Communication The process of how information is communicated amongst care providers among staff sn that optimal patient care is provided this include inter discipline intra members discipline inter department and intra department Availability of The care provider has all information needed available in a useful format to information provide patient care The organization has access to information in a useful aggregated format so that patient outcomes can be improved This includes individual and hospital performance in patient care governance Management and support processes Adequacy of The adequacy of how technological supportis used when commercially technological available to provide optimal patient care and minimize errors associated Support with human failures Equipment The hospital s plan ta maintain equipment was followed and is an effective maintenance pla
25. by clicking the Rest Password button and following the instructions on the screen For convenience the user will be notified about how to obtain login information by means of email 15 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FACILITY MANAGEMENT Care Area Administration In PA PSRS each event report includes a question Number 5 about where in your facility the event occurred The PA PSRS data analysis function allows you to analyze your facility s reports by location and ask such questions as e What locations in our facility most frequently report medication errors e Do reported patient falls in some locations result in more serious injuries than falls in other locations e Two general patient floors have vastly different rates of reports of a certain type of Serious Event Is one floor really safer than the other or is staff on one floor more compliant about reporting events In order to help you identify the locations of events in your facility PA PSRS allows you to establish care areas for your facility Establishing care areas simply involves e Developing a list of locations in your facility e g Third Floor West Wing or 3 West e Coding each care area for the area type e g burn unit pediatric unit psychiatric unit adolescent med surg etc Adding Care Areas To establish your facility s care areas follow these steps 1 While logged in as the Facil
26. care areas individually each time you generate a report As another example even in a single facility you could group clinically similar areas together as a group such as all general med surg floors To establish your facility s Care Area Groups follow these steps 1 While logged in as the Facility System Manager position your mouse over the Care Areas menu option 2 Click on Add Group in the pop up menu 3 Inthe first dialog box enter the group name 4 Click Save PA Pennsylvania Patient Safety PSRS Reporting System Wednesday September 14 2005 Heip Falls Program BU A LC E Repeat these steps for each group you wish to define in your facility Add Group To update your facility s Care Area Groups follow these steps 1 While logged in as the Facility System Manager position your mouse over the Care Areas menu options 2 Click on Edit Delete Group in the pop up menu 3 Click the group name to be edited or deleted 4 Change the group name or select care areas to be assigned to the group and click Save or click the Delete button to delete the group 5 Aconfirmation box will be presented to confirm the delete option VERSION 6 5 18 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FACILITY MANAGEMENT PA Pennsylvania Patient Safety PSRS Reporting System Wednesday September 14 2005 Help Edit Delete Groups Ho Group Hame
27. creme Fi Pms ete Poe Dera manda alm a rocard MA Ced bona n 6 pe qnem me Fae Conci drones na COO meee Pot Wam F a Otter Pome pci en oo oO ee Foa kmi pa ryviom v turam rie deme o g beani em mucrone rmi mtm intem aat pT preter c Lewer el mater prem LIT m helm arnb and pale cr rectos Seber ipii na mites kiiy pte h ad comam dias cem FATT Poe OB Frw Drs f B HIT Comrisdeq F actes check adi foa appe F a Lem or dior ol dts M amp fyrem mura or mores da Dat boni eot math palet Foa mage told rti orm on wt mago union gacnet a cese wet reeds Tf manto bews progrummang cd an og bomen a ngpo dert Po Che Fhar Spec oo ao F oa Hedra ber atm e q mboi pin emnt fer usn amp Cam eatery ow iae OF qoom or rincon lame palet wrong promis wes drag weseq dee Pe himaan dephey or pipea 0 fet men color of fet nc aon of airm a glay irem A am Len darm lage Fe Che Okar Spec I Vins elas ema Po tncempanhdey emer dnm M byger im mantenance a Hoire fables oc pia Pod Meneuh abes or proche bort wa a rian ndra ors f Verpete piret bap ora Ug w M Oie Pae ipea C Dems Limbo Oda Demon Amo atom ame fe tea m tpm f Nest Page Tog oi Page Cancel Ret c Qu 14 0 Cent ona 3M Hoa os a hose om PR ee ee dope ee code eee Gm xs le m a Gv G ab c3 m amd e Pa me 6 msc oum ROT oum pcm mue E VS Re
28. facility care area by PA PSRS NOTE if there are problems with this information or missing care areas contact PA PSRS to make the appropriate corrections The third column has boxes to enter in patient day data and patient encounter data for each unit or care area The PA PSRS care areas for patient day data include General medical surgical units Intermediate units e g telemetry units step down units Inpatient psychiatric units 98 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM VERSION 6 5 Inpatient rehabilitation units Pediatric care units opecialty units e g oncology units orthopedic units Critical care units The PA PSRS care areas for patient encounter data include Emergency Department Radiology Rehabilitation Services Outpatient Clinics Inpatient Patient Days In the third column of the first table titled Patient Days enter the number of patient days for the month in the box next to each of your institution s designated facility care areas It will also be required to enter in your institution s number of total facility level patient days data It is suggested to collaborate with your finance department to obtain this number At the bottom of the inpatient table there is a line titled Total Facility level Patient Days Place the total number of facility level patient days in the box at the right The total facility level patient da
29. facility may designate more than one individual to serve in the PA PSRS User role This will enable several people to submit reports directly to PA PSRS on behalf of the facility Please be advised however that the Patient Safety Officer identified in the facility s MCare required Patient Safety Plan is ultimately responsible for all reports submitted to the system Therefore be careful and exercise good judgment when deciding to whom you will grant this responsibility Nevertheless we recommend that each facility designate at least one other individual with patient safety or quality management responsibilities to serve as a PA PSRS User particularly as a point of contact during periods when the primary PSO is unavailable Each PSO and each delegate they establish will receive a unique ID and password for accessing the system Each facility must notify the Authority of any changes in its PSO To do so go to the Authority s website which is accessible via a button on the left side of the PA PSRS sign on screen Click on the Facility Reporting Information link in the left hand menu There you will instructions for updating the name and contact information for your facility s PSO The third role is that of the Read only PA PSRS User Users who are assigned the Read only user role are restricted from submitting or amending reports This user role has access to the system for the following purposes e Viewing and printing reports e Analyzi
30. hospitals to report to DOH a any death in restraints or seclusion or b in which restraints or seclusion were used within 24 hours of death other than soft wrist restraints Frequently Asked Questions Are there any rules of thumb that can help us determine whether a report is a Serious Event Incident or Infrastructure Failure Facilities are responsible for coding reports Patient Safety Officers should consult with their Patient Safety Committees and risk management staff in determining when an event is reportable and if so as what type However we can provide the following guidance 1 VERSION 6 5 If there was any harm to a patient while the patient was receiving clinical care the report should be coded as a Serious Event with exceptions listed in number 2 below 20 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 2 Reports in which a patient was harmed by a criminal behavioral and or intentionally unsafe act should be coded as Infrastructure Failures Please see PA PSRS Program Memorandum 2005 03 Reporting Crimes or Potentially Criminal Activity in Appendix C 3 Further guidance was detailed in the notice titled Final Guidance for Acute Healthcare Facility Determinations of Reporting Requirements under the Medical Care Availability and Reduction of Error MCARE Act in The Pennsylvania Bulletin dated September 27 2014 Please see P
31. i e existing events reported for the care area being attributed to the new care area Example The nursing unit 8 West is renamed 8 Harris thanks to the generosity of a hospital donor The FSM changes the name of the care area in PA PSRS to reflect the change on October 31 At the end of the year a report of events occurring from January to December on 8 Harris will include any event reports or other information entered into PA PSRS prior to October 31 when the unit was known as 8 West Changing the name of a care area type will result in historical i e existing events reported for the care area being attributed to the new care area type Example The nursing unit 6 North has changed from a General Medical Surgical Unit to an Inpatient Rehabilitation unit The FSM changes the name of the care area type in PA PSRS to reflect the change on June 30 At the end of the year a report of events occurring from January to December for the Inpatient Rehabilitation care area will include any event reports or other information entered into PA PSRS prior to June 30 when the unit was considered a General Medical Surgical unit Deleting Care Areas Deleting a care area will remove it from the list of care areas available for entering future event reports Deleting a care area does not delete the events or utilization data previously reported for that care area The events reported for that care area will remain in the PA PSRS system and any events or uti
32. not in place 4 Events E Patient not at risk and prevention sirategies not in place 2 Events 418905 Incident 7 2 2012 sitting in chair wheelchair inpatient 194627 Incident 7 23 2010 Found on floor inpatient E Patient not at risk and prevention strategies unknown 2 Events m Patient risk unknown and prevention strategies unknown 8 Events Falls Dashboard By default the Falls Dashboard displays information from the most recent month of complete data For best viewing of the dashboard set the zoom to 100 in the drop down box otherwise the chart in the dashboard will overlap the tables and quartile report jd 4 1 oti b Ji 100 il Page Width Whale Page dice hboard 5e Suns gt September 2012 rents 0 Incident Events 7 7554 S05 255 Falls Risk WE uM A screenshot of the complete Falls Dashboard is shown below Each component of the dashboard will be described in further detail VERSION 6 5 117 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Periodic Falls Rates per 1 000 Patient Days 3 5 25 15 0 5 Falls Dashboard June 2012 to June 2012 Falls Events forthe facidy 30 Senous Events 1 Incident Events 29 Enrollment Dale Ape 1 2012 Enrollment Care Area Unit Level Falis Risk Assessment No Response Falls Risk Assessment Completed Patient identified atRiskotFall Identified Patient identifie
33. of airm a glay irem A am Len darm lage Fe Che Okar Spec I Vins elas ema Po tncempanhdey emer dnm M byger im mantenance a Hoire fables oc pia Pod Meneuh abes or proche bort wa a rian ndra ors f Verpete piret bap ora Ug w M Oie Pae ipea C Dems Limbo Oda Demon Amo atom ame fe tea m tpm f Nest Page Tog oi Page Cancel Ret c Qu 14 0 Cent ona 3M Hoa os a hose om PR ee ee dope ee code eee Gm xs le m a Gv G ab c3 m amd e Pa me 6 msc oum ROT oum pcm mue E VS Rena Reus Ihn Acker Aj qu aures VERSION 6 5 54 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 Screen 7 Follow up Questions Questions 16 22 In many cases you may not be able to answer with certainty the Follow up Questions at the time you are completing an initial report When this is the case provide answers that best represent your current understanding of the event You can amend the report or provide additional information for up to 90 days after submitting your initial report Later in this chapter we provide instructions on how to amend an existing report You may revise your responses to these questions after additional investigation ranging from simply discussing the event with the individual who reported it through your facility s internal reporting system all the way up to a formal root cause analysis or
34. of stay C Minor surgery CI Major surgery O System or processes delay care to a patient C To be determined O ther specify maximum 250 characters 22 her Comments maximum 250 characters Submia Repori e Answer these questions by following the directions on the screen using the check boxes and menus provided e When you are finished with this screen you may click on Submit Report VERSION 6 5 57 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS When you click Submit Report you are filing a report as defined by MCare If the report is a Serious Event it is submitted to the Patient Safety Authority and the Department of Health If the report is an Incident it is submitted to the Patient Safety Authority If the report is an Infrastructure Failure or Other event it is submitted to the Department of Health If you fail to click Submit Report from this screen or if you stop entering information at any point before reaching this screen the report will not be submitted and your data will not be stored in PA PSRS When you do click Submit Report you will see the screen shown below which asks you to confirm that you are ready to submit the report Microsoft Internet Explorer This Infrastructure Failure event will be reported to the PA Department of Health By submitting this report you attest that Ehe information provided is accurate and complete t
35. on the Additional Criteria link as shown below before clicking the Generate Report button Report Selection Criteria Summary of Submitted Reports by Type Facility Harm Score Trends by Month Harm Score Distribution Report style Chart Tabul Event Detail by Harm Score 3 j ES Distribution of Sub Categories Report Submission Type Serious Event Top 3 Event Types by Care Areas High Alert Medications and Steps In The Medication Process Incident Falls Rates Report Falls Rates Facility Report Falls Rates Report Inpatient vs Outpatient Care Areas Falls Risk and Strategy Process Measure Falls Dashboard Generate Report GoTq Additional Criteria f Main Page The program enrollment level and type of report selection will determine the list of configurable options ALL FALLS REPORTS except the utilization data report include the following configurable options Report submission type Falls report rate report includes Incident and Serious Events default Falls with harm report rate report includes Serious Events only Periodicity time period Monthly default Quarterly Yearly Time Frame Select the time in months for each report No dates may be selected prior to the month and year the facility enrolled in the falls program VERSION 6 5 108 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM FALLS RATES REPORTS include the
36. options When the Click for more details link is selected a detailed list of the patients who are represented in each box of the 2 x 3 table are displayed as shown below Event ID Risk and Strategy Process Measure July 2012 to July 2012 Event Classification Event Date amp Patient at risk and prevention strategies in place 22Events E Patient at risk and prevention strategies not in place 4 Events Patient Status Harm Score E Patient not at risk and prevention strategies not in place 2 Events B Patient not at risk and prevention strategies unknown 2 Events El Patient risk unknown and prevention strategies unknown 3 Events LLIILIILILILILILILLL K V iki Dh Click on one of the signs and the list of event report information i e event ID event classification event date fall type patient status and harm score will appear as shown below To close this list of patients click on the sign for the open category VERSION 6 5 116 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Risk and Strategy Process Measure July 2012 to July 2012 Event ID Event Classification Event Date Fall Type Patient Status Harm Score E Patient at risk and prevention strategies in place 22Ewvients E Patient at risk and prevention strategies
37. other investigative technique PA PSRS allows you to record and analyze the results of your own investigations g oe Tuesday September 13 2005 P Pennsylvania Patient Safety Time remaining EEE PSRS Reporting System Reset Timer Help Event Report Organization Training Facility 16 Potential Contributing Factors check all thal ipii be a Teaan Facto s 1 Based on Harm Store selected no response is needed CI Communication problem betwren providers C Change of amp eerdce same care area CI Cross coverage situation O Shit change Unplanned workload increase O Holiday Hone Ta be determined b Work Errai operit Based on Harm Score selected no response is needed n Distractionsmnberrupiiong Limited access to patient information Poor lighting C High moise hevel Equipment malfunction inadequate equipment availability C None C To be determined Task Factors Based on Harm Score selec led no response is needed COl Training issues LI Emergency smuabon inexperienced staff inadequate residen supervision Cardiacimespiratory amest situation a Order eniry zystem prablern Hone Te be determined Saf Factors Based on Hann Store selected no response is needed O use of foal siat Use of agency temporary or traveling staff CI Staff scheduling issues inadequate eyetem for cavering patient care insufficient staff Fatigue
38. rates with other enrolled hospitals across the state Appendix A Blank Forms provides hardcopies of the portions of PA PSRS used in reporting events which may be useful in coding submitted reports Appendix B Event Type Taxonomy provides the complete list of event type codes used in PA PSRS Appendix C Selected Program Memoranda provides policy guidance from the Patient oafety Authority 2 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE INTRODUCTION The Scope of PA PSRS VERSION 6 5 The PA Patient Safety Reporting System PA PSRS is a mandatory confidential statewide information system for reporting of events occurrences or situations that have or could have resulted in unanticipated injury to a patient in an MCare covered medical facility Covered facilities include hospitals ambulatory surgical centers abortion facilities and birthing centers licensed as healthcare providers in the Commonwealth of Pennsylvania PA PSRS will collect four general types of reports e Reports of Serious Events e Reports of Incidents e Reports of Infrastructure Failures e Reports of Other events These terms are defined in MCare or in the latest guidance for reporting see Figure 1 1 Serious Event An event occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring
39. saved enrollment option choice select the Cancel button on the enrollment screen To change your enrollment status at any time please follow the program enrollment steps on the previous page NOTE If your facility chooses to un enroll from the program you will still have access to any data you entered during the time of enrollment To see the assignment of facility care areas to PA PSRS care areas and falls tracking groups click on the Falls Units button The falls unit care area list that will appear on the screen can be printed be clicking on the Print button at the bottom of the screen 95 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Care Areas Units for Falls Tracking Inpatient Care Areas Care Area Care Area Type Falls Tracking Group 1AOrtho Medical Surgical Unit General Medical Surgical Units CardiacCareUnit Cardiac ICU Critical Care ChestPainEvaluationCenter Cardiac Intermediate Unit Intermediate Unit InpatientPT Renal Unit specialty Units IntensiveCareUnit Medical Surgical ICU Critical Care CardiacCareUnit Cardiac ICU Critical Care Outpatient Care Areas Care Area Care Area Type Falls Tracking Group DepartmentofMedicine Physician Practice Outpatient Clinics DepartmentofSurgery Physician Practice Outpatient Clinics EmergencyDepartment Emergency Department Emergency Department NuclearMedicine Imaging Nuclear Medicine Radiology Services Occupat
40. score no response is required Some Infrastructure Failure reports e g power failure will not involve a particular patient In such cases you may answer questions such as patient age admission date and other patient specific questions as Not applicable 22 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS For reports of Incidents only the first 12 questions are required However while Questions 13 21 are not required for report submission we encourage you to answer as many of these questions as possible Report Submission Incidents and Serious Events To submit a new report to PA PSRS you must be logged onto the system as a PA PSRS User as opposed to the Facility System Manager or a Read Only user From any screen follow these steps e Place your cursor over the Event Report box in the Navigation Bar A drop down menu will appear Click on Create New Event Report Screen 1 e The next screen that appears see below asks whether you are reporting a Serious Event Incident or Infrastructure Failure Check the box next to the appropriate report type Click Definitions for help identifying the report type e When you have selected the report type click Next Page to proceed to the next screen Helpful Tip At any point during the report submission process you can click on the Help link in the upper right hand section of the s
41. that were reported to have a fall precaution protocol in place If event reports do not indicate whether or not a falls risk assessment was completed this is noted below the chart Unexpected Follow up Suggested is displayed to indicate falls reports that may reveal a mismatch between falls risk assessment and implementation of falls prevention strategies e g falls reported in patients assessed and identified at risk to fall without falls prevention strategies in place VERSION 6 5 115 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE Risk and Strategy Process Measure for serious and incident fall events in the facility July 2012 to July 2012 Your facility s total number of events is 38 22 4 Yes Unexpected Expected Followup Suggested n 2 No Unexpected Followup Expected Suggested Note Number of patients who had unknown response or no response to the risk assessment question Click for more details FALLS REPORTING PROGRAM Yes Ho Unknown 0 Unexpected Followup Suggested 2 Unexpected Followup suggested This report may be modified to display only Incidents or only Serious Events It may also be modified to display information from falls reported for specific Falls Tracking Groups e g only Pediatric units or for individual care areas e g 5 West Click on Select New Criteria for additional configurable
42. the patient status definitions will appear on the screen To close this pop up window select the close link Definitions Inpatient e Any admitted patient including observational patients that receive care in a hospital unit e g med surg unit critical care unit pediatric unit etc Ths includes any patient who is formally admitted while in the emergency room and is being he d while waiting for a room Outpatient e Any patient who receives care in the hospital without being admitted e g emergency room rehabilitation services radiology This defnition includes emergency room patients prior to ormal admission and emergency room observational patients Ths EXCLUDES any patient who is ormally admitted while in the emergency room and is being held while waitng or a room It also includes patients who receive care in an ambulatory surgical facilty birthing certer and abortion facility Unknown e Patients designated as unknown are assumed to be either npetiert or outpatient 2ased on the repo ted location where the event occurred including falls for the purpose of calculating alls rates Close e The patient status field is used in calculating falls rates reports Limiting the use of the Unknown field will improve the accuracy of falls rates reports For complete instructions for Fall Event reporting please read Chapter 8 Falls Reporting Program e All reports from Ambulatory Surgical Facilities ASFs B
43. when conducting interviews with healthcare workers who report events internally or you may even choose to incorporate blank forms into your facility s internal reporting system To access the blank forms click on Blank Forms from the Navigation bar then select which form s you want from the pop up menu All forms are provided in Adobe Acrobat format Viewing and printing these files requires Adobe Acrobat Reader a free software application available from Adobe Systems Incorporated To obtain this software under the Blank Forms pop up menu select Download Adobe Acrobat and follow the instructions on the screen Anonymous Reports Under MCare healthcare workers may submit anonymous reports of Serious Events directly to the Patient Safety Authority if they have previously complied with section 308 a of the Act The availability of Anonymous Report forms offers additional opportunities to promote patient safety and you are encouraged to print and distribute copies of the form in your facility The form is available via the Authority s website as well as through the PA PSRS program Resources VERSION 6 5 You can access training materials and system update information on line while logged in to PA PSRS These may be used as reference material and or training aides To access system resources click on Resources from the Navigation bar then select which resource you want to access from the pop up menu 64 JUNE 2015
44. 05 13 34H Treatment Test From this page you can sort your reports by several criteria simply by clicking on the blue up and down arrows beneath the column headings For instance e If you want to view your most recent reports clicking on the down arrow in the column labeled Date amp Time Report Submitted will sort your reports in reverse chronological order e f you want to focus on your reports with the most significant harm score click on the down arrow beneath the column heading Harm Score e fyou want to see all reports of medication errors at once click the up arrow under the column heading Event Type e Oneach screen 10 reports are shown To screen through more reports click Next or click on a specific page number Helpful Tip The column TBD displays a red flag to denote any report with To be determined selected as a response to one or more questions When a submitted report is viewed or printed the following message will appear in the header section near the top of the report This report has one or more fields marked To Be Determined You can sort the list of reports by this column to easily identify those reports requiring attention By default this screen shows reports submitted in the past 90 days To filter this list for a shorter timeframe click on New Date Range just below the menu bar as shown below a j OX PA 8 Pennsylvania Patient Safety 2l ht
45. 05 Jun 2005 Jul 2005 Aug 2005 Sep 2005 Month E ALL Unsafe Conditions Harm Score amp Event No Harm Harm Score B1 B2 C D Event Harm Harm Score E F G H Event Death Harm Score Harm Score Definitions PA PSRS Statewide Aggregate Harm Score Trends by Month of Reports Jan 2005 Mar 2005 Apr 2005 May 2005 Jun 2005 Jul 2005 Aug 2005 Sep 2005 Month Built using ChartF X Development Test version w ALL Unsafe Conditions Harm Score A Event No Harm Harm Score B1 B2 C D Event Harm Harm Score E F G H e Event Death Harm Score Harm Score Definitions VERSION 6 5 76 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Harm Score Distribution This report presents either as a pie chart or table the number or percentage of reports by harm score among all reports submitted From the main report selection page you can choose to show any combination of report types Serious Event Incident or Infrastructure Failure By selecting Additional Criteria you can modify the report by event date gender or age of affected patients care area or event type In addition to showing your facility s data this report also presents aggregate statewide data for comparison PA 3 Pennsylvania Patient Safety Tuesday Oc PSRS Reporting System Organization EDS amp A Harm Score Distribution R Selection Criteria Report Style
46. 1 4 5 8 VERSION 6 5 43 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Screen 5 Health IT Question 13 e Question 13 asks you whether Health IT caused or contributed to the event e Click Next Page when finished VERSION 6 5 44 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS LE Dad Picea T cann ar cominfioake te fen nmt F Ya PF gs 7 Osee A Whe kh rai T Pree canes ur anie vo ee Deer ioo al op appr oa Ees panes dex Fy Ferdi peered niki nam Fs Giy rom Pd Umen Uo Cer Parana Decir m p ES reser DN ED of PD T oa Corgan rondes arde sum OME cett CO Aaner emma US Dares ada dm cde nim md MAR do Ce d a eum poppe semen Va Ced khaa sa COR remm Pit tie Fa Des fhe Scc m At sra mun mr ee der ica Rmi Ta Eea aper demos p ag run rhag pei E a p a peer Pie Laberana pirena pemem 271 We dep na p ara palier rem Ud Pll lage te a rri Bldg petet qma aol ioci dele Ir TRATTO oa Ces Frw a as B HM Cg lakes heh al Rub apu a oa Lam wr dele of de Py fpem miru m torre date Psal ons mod mal pas mat a aS agi a F i age riaa eet jem ated Fo pata irt japana drama Pog beter n p dieit Uo Dia Fiar Denier F a Padres ben tems og rieri pla emma em ae Pe Eui mmy eee SI LL EL eg pe ey pee erg ie eg ee F oa bime hepier we wfengra uade oc poo fmt mete
47. 7 DR I 9g E cheat 88 gp VA RORY arash 90 III INS sacra eee 92 PORT TOLON cane rn ee errr 0 M 92 PATEN C AER ORS o nasicsrcat tudine mina tu MUR ted sem cation NAM TOME CENE MI RM ME 92 PATE Ni SABE ye RECOMMENDATION atas pon exista epo ti Dua dq E nondum N TOS C NDA PERDRE d ME 92 PROGRAM ANNOUNCEMENTS AND SYSTEM ADMINISTRATION eeeeeene teet tn tnnt nn enne tn sensns ennt nn stas tns tns tn senses enne tn etnia enn 93 P DE quu 93 FALLS REPORTING PROGRAM Daas diouicibsbius inen v UP OR IRURE DIU RUNE T DNI DU 94 ge e URSI EN 94 PROGRAM E NROLEMEN T X 94 MERU EOIN a A T E E E TE A 96 98 Unit Level Utilization Data Entry vecccccccccccccssccssscessccsscesssscesscesecesscessesssecssseesuecessecsaeceseeseascesseceeeesseceseeseaeceseecesecesseseeeesaeens 98 Amending Unit level Utilization Data ccccccccccscccssccesscsssceeseeseeesseeseeesseessecssecsssecsuecsseesssecnseecsaeceseecesscesueceseeesseseseecnaeeeseens 100 Facility level Utilization Data Entry vicccccccccccccessccssccsssceesscsscssseessseesseesecssseessecessseuecessecsaeces
48. A 3 Pennsylvania Patient Safety Time remaining EEN PSRS Reporting System Help Event Report 9 Describe Th Event Please include all relevant information including details an how or why the erent occured maximum 1000 characters T0 Harm Score check ona Ups ade a ef eT ie se O A Circumstances that could cause adverse events e g look alike meditations confusing equipment ex CO B1 An event occured but Itdid mot reach the individual near miss or close call because of chance alone B2 An event occured but itdid not reach the individual fnear miss or ciose call because of active recovery efforts by CM egiver s An event occurred tat reached the individual but did not cause harm and did nel require increased monitoring an error of omission such s a missed medication dose does reach the individual O D An evenit occuered hal required mentoring to conin that tt resulted in mno harm and or required intervention t pr essent Diar Event Haan E An event occured that coritributed to or resulted in temporary harm and required treatment or intervention F An event occurred that contributed to or resulted in temporary harm and required initial or prolonged hospal alization G An evenit occured that contributed to or resulted in permanent harm H An evenit occured thal resumed in a near death event e g required ICU care or other intervention necessary to sustain life Eyes deah O Lan
49. A PSRS Program Memorandum No 2015 02 in Appendix C 4 Use the Harm Score see Chapter 5 to distinguish between Serious Events and Incidents The Harm Score measures the extent to which a patient safety event reached the patient and the severity of the event outcome for the patient In general a Harm Score of D or below is consistent with an Incident while a Harm Score of E or above suggests a Serious Event 5 When in doubt about which of two or more harm scores is appropriate to a particular event select the higher harm score that seems appropriate 6 When in doubt about which of two or more event types is appropriate select the one that seems most specific Can a single event ever be both a Serious Event and an Infrastructure Failure PA PSRS treats Serious Events Incidents and Infrastructure Failures as three mutually exclusive categories In PA PSRS a report must be coded as only one of these three types of reports However some events may not be easily defined In these cases the following rules will help to minimize the chance of miscoding In cases where you are choosing between Choose Serious Event and Incident Serious Event Serious Event and Infrastructure Failure Serious Event Incident and Infrastructure Failure Infrastructure Failure Should we report events in which a patient is injured by something other than a clinical process Facilities must use their own judgment in deciding how broadly to interpret the ph
50. ANALYSIS Harm Score Trends by Month This report presents either as a line graph or table a time series showing the total number of reports submitted over a series of months by harm score The reports stratify the harm scores into the following five clusters All includes all reports of any harm score Unsafe Conditions Harm Score A Event No Harm Harm Scores B1 through D Event Harm Harm Scores E through H Event Death Harm Score l From the main report selection page you can choose to show any combination of report types Serious Event Incident or Infrastructure Failure By selecting Additional Criteria you can modify the report by event date gender or age of affected patients care area or event type In addition to showing your facility s data this report also presents aggregate statewide data for comparison PA 2 Pennsylvania Patient Safety Wednesday September 14 2005 PSRS Reporting System Organization Training Facili Help Harm Score Trends by Month Selection Criteria Report Style N Report Submission Type Serious Event Incident Infrastructure Failure Event Date Current Year Gender All Age All Care Area All Event Type ALL M Regenerate Report Select New Criteria Choose New Report Return to Main Page File Edit Tools View Gallery Facility Harm Score Trends by Month of Reports y muc c Ec oo de r a T m A A Jan 2005 Mar 2005 Apr 2005 May 20
51. ANUAL AND USERS GUIDE DATA ANALYSIS 2 Enter a date range for the reports you wish to download Note Date ranges may be no larger than one month for each file you create with this feature To create spreadsheets with longer date ranges you will need to perform multiple downloads 3 Press the Export button 4 You will be presented with a choice to save the download file to your computer or to open the file see below To save the file press Save and select a location and filename using the dialog boxes presented To open the file press Open For the file to open properly you must have a spreadsheet program such as Microsoft Excel already on your computer PAS Pennsylvania Patient Safety Wednesday September 14 200 Reportin system Organization Training Facili Help File Download Export Data This utility will export a list of submitted repo note Date ranges are limited to 31 day intervals Please enter the criteria Some files can harm your computer If the file information below looks suspicious or you do nat Fully trust the source do not open or save this file File name P5A ExportFile csv O File type Microsoft Excel Worksheet Export data based on Event Date From edseqov iN This type of file could harm your computer if it contains Start Date 09 01 2005 ES malicious code Would you like to open the file ar save iE to your computer End Date 09 13 2005 E Go Ta Main
52. C Issue related to proficiency O issue related to impairment None Ta bie determined 55 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 e Patient Clas acteristics E Based on Harm Score selected no response is needed O Lack of palient compliancefadherence ls C Lack of patient understanding O Language barrier oO Lack of famihr menter cooperation None To be determined f Organizational Management C Based on Harm Score selected no response is needed C No 24 hour pharmacy inadequate bed availability Presence of boarder patientidifferent serite L efinitions Presence of observation patient Lack of policies and procedures Unclear or ambiguous policies and procedures Procedures not followed C None C To be determined g C Other please specify any additional information maximum 500 characters 17 Wehal Was Done To Remedy The Situation Or Reduce Its Likelihaad Far Recurrence check all that apply Based on Harm Score selected no response is needed C Talked with patientramibr C Arranged for support of staff member involved o Discussed tha eventwrh the involved healthcare worker Discussion with staff of unsafe practices Physically removed equipment or supplies O Stati orientation process Education or training of staff Documentation procedures C Modified staffing pattern or workflow Referr
53. Chapter Report Coding How to get the most from your facility s data Classification Systems PA PSRS uses several taxonomies or classification systems for coding the data you submit in your reports The benefits of using such systems are e By using checklists or drop down menus they allow you to submit more detailed reports much faster than you could if you had to type everything in manually e They facilitate faster database searching e They make it possible for you to perform more advanced analyses of your own data by supporting more sophisticated database queries e They make it possible for you to develop meaningful comparisons of your facility s data to aggregate de identified data from other facilities Some of the taxonomies used in PA PSRS which we will discuss in more detail throughout this chapter include systems for classifying data about e Severity of a Serious Event Incident or Infrastructure Failure e Event type e g medication error fall etc e Root cause analysis Report Severity In any patient safety reporting system some reports are more significant than others For example a report of an unexpected patient death is generally considered more significant than a report of a minor bruise The level of follow up by the Patient Safety Authority will also likely relate to the Significance ascribed to the report A Patient Safety Officer will no doubt spend a considerable amount of eff
54. Medications and Steps In The Medication Process Help Selection Criteria Report Style Chart Report Submission Type C Serious Event v Incident Event Date Current Year Gender All Age All Regenerate Report Select New Criteria Choose New Report Return to Main Page File Edit Tools View Gallery Facility High Alert Medication Distribution Associated with Medication Errors Oral methotrexate non oncologic use Oral hypoglycemics Opiates Narcotics Nitroprusside sodium for injection Neuromuscular blocking agents Nesiritide n 3333333232222222222232323233933423223232323 Low molecular weight heparin injection Liposomal forms of drugs e g liposomal amphotericin B Lidocaine local anesthetics in large vials Iv unfractionated heparin Iv thrombol yticsAibrinol ytics e g tenecteplase Iv Theophylline IV radiocontrast agents IV Potassium IV moderate sedation agents e g midazolam Iv Magnesium Sulfate Iv inotropic medications e g digoxin milrinone IV Calcium IV amiodarone IV adrenergic antagonists e g propranolol WV adrenergic agonists e g epinephrine Insulin Hypertonic sodium chloride Sodium Chloride greater than 0 9 concentration Hypertonic dextrose dextrose greater than or equal to 20 Glycoprotein IIb Illa inhibitors e g eptifibatide General anesthetic agents inhaled and IV e g propo
55. N 6 5 111 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Facility Falls Rates January 2013 to January 2013 5 4 E a T aut Jan I 9913 _ ____ wie Facility Falls Rate A facility falls rates report comparing falls rates over a specified time period with the peer group periodic falls rate i e the comparison falls rate will fluctuate with each time period is shown below Facility Falls Rates vs Peer Group Facility Falls Rates June 2012 to August 2012 Peer Group Acute Care Hospitals over 300 beds Falls Per 1 000 Patient Days Jun Jul Aug MQ 9994 2 w Facility Falls Rate t Peer Group Periodic Falls Rate Peer Group PeriodicFalls eve PEE Group PeriodicFalls Rate Upper ConfidenceLevel Rate Lower Confidence Level M missing data A maximum of 21 facilities are included in the comparison group calculation Each time period is calculated separately and ifs possible that each time penod has a different number of facilities that are included in the comparison group calculation The comparison group calculation must have af least 5 facilities to work VERSION 6 5 112 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM A facility falls rates report comparing falls rates over a specified time period with the peer gr
56. NSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 e Patient Clas acteristics E Based on Harm Score selected no response is needed O Lack of palient compliancefadherence ls C Lack of patient understanding O Language barrier oO Lack of famihr menter cooperation None To be determined f Organizational Management C Based on Harm Score selected no response is needed C No 24 hour pharmacy inadequate bed availability Presence of boarder patientidifferent serite L efinitions Presence of observation patient Lack of policies and procedures Unclear or ambiguous policies and procedures Procedures not followed C None C To be determined g C Other please specify any additional information maximum 500 characters 17 Wehal Was Done To Remedy The Situation Or Reduce Its Likelihaad Far Recurrence check all that apply Based on Harm Score selected no response is needed C Talked with patientramibr C Arranged for support of staff member involved o Discussed tha eventwrh the involved healthcare worker Discussion with staff of unsafe practices Physically removed equipment or supplies O Stati orientation process Education or training of staff Documentation procedures C Modified staffing pattern or workflow Referred issue to another department identity oO Rietened issue to medical leadership or administrative leadership go
57. PROGRAM MEMORANDUM No 2013 02 PA PSRS SECURITY UPDATE LOGGING IN TO PA PSRS 177 ING Spaces Allowed in a PASPSRSS User TD sa o ec tent hen oa Eo a a nien eis dac Gestor ai ehe 177 New Forgot Password Butictolaliby see cc esee a A E EA A O 177 PSRS Password and User Tel very sts eI casco get tec an deal sg a Ete Di Ted Atque 180 Enhanced Password SECUN RR 184 How FSM Users Can Identty Desal PSOne oce eee ab ee TOM eb pH Ra di Ei al hel alia eG D bo ED oe 189 VERSION 6 5 Hi JUNE 2015 Chapter 1 Introduction Using the PA Patient Safety Reporting System to improve healthcare safety and quality VERSION 6 5 The purpose of this Training Manual and Users Guide is to help Pennsylvania healthcare facilities to improve the safety and quality of the care they provide to patients The Medical Care Availability and Reduction of Error Act of 2002 also known as Mcare or Act 13 of 2002 established the Patient Safety Authority the Authority as an independent agency of the Commonwealth The Authority is charged with taking steps to reduce medical errors by identifying problems and recommending solutions that promote patient safety in Pennsylvania healthcare facilities MCare required Pennsylvania hospitals ambulatory surgery centers behavioral health centers and birthing centers to report to the Authority on the occurrence of Seri
58. PSRS You will know if a report has been amended by looking at the Report ID number see screen below If a Report ID ends in a hyphen followed by a two digit suffix e g 0123456 01 this indicates that the report has been amended since its original submission The two digit suffix indicates the number of times the initial report has been revised e g 0123456 01 indicates that there has been one amendment to the original report 0123456 02 indicates that there have been two amendments 0123456 05 indicates that there have been five amendments etc VERSION 6 5 62 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS PA 3 Pennsylvania Patient Safety Wednesday Saptemiber 14 2005 PSRS Reporting System Organization Training Facili Help Analytical Data Tools Date Range 08 02 2005 to 08 31 2005 new date range Showing 1 20 of 23 Total Records Selected Report ID Report ID TBD p CareArea Event Type pee ee postion Event Date amp Time uaa t4 tL TY t4 tL t4 tL tL TL 48980 03 Serious 3West DL Fall a E 75 08 29 2005 12 22 8 30 2005 16 20H 48971 le Incident 3 West D Fall C 75 08 23 2005 Unknown 8 30 2005 16 17H 48952 ncident 3 West D Fall B2 75 08 23 2005 Unknown 8 30 2005 16 14H 48953 Incident 3 West D Fall Bi 75 08 30 2005 Unknown 8 30 2005 16 12H To see a report history for a particular event report follow thes
59. Page The following data elements will be included in the downloaded file Report ID Submission type i e Serious Event Incident or Infrastructure Failure Person submitting the report Event location i e care area Event type e g medication error fall etc Harm score Event date Event time Likelihood of recurrence Frequency of recurrence Days remaining to amend report Date of last report update Date of report original submission VERSION 6 5 89 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Advanced Data Export Advanced Data Export allows a user to export either all or just some of the elements that make up a PA PSRS report Select which data elements to export by choosing individual question numbers If a question is selected for export all data associated with that question will be exported For example if the user wishes to include Harm Score in the data export simply make sure question 10 Harm Score is checked off on the criteria selection screen To include data related to where in the facility the event occurred the user would check question 5 Care Area when selecting which data fields to export see below PA i Pennsylvania Patient Safety PSRS Reporting System Advanced Data Export Select the data elements you wish to export by choosing the appropriate PA PSRS question number The data will be exported in XML format Thursday Apr
60. Report Submission Type v Serious Event v Incident v Infrastructure Failure Event Date Current Year Gender All Age All Care Area All Event Type ALL v Regenerate Report Select New Criteria Choose New Report Return to Main Page e oe Facility Harm Score Distribution Harm Score Definitions PA PSRS Statewide Aggregate Harm Score Distribution Harm Score Definitions VERSION 6 5 77 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Event Detail by Harm Score This report presents either as a series of pie charts or as a table the number or percentage of reports by event type e g falls adverse drug reactions etc among all reports submitted according to the following harm score clusters Unsafe Conditions Harm Score A Event No Harm Harm Scores B1 through D Event Harm Harm Scores E through H Event Death Harm Score l From the main report selection page you can choose to show any combination of report types Serious Event Incident or Infrastructure Failure By selecting Additional Criteria you can modify the report by event date gender or age of affected patients care area or event type In addition to showing your facility s data this report also presents aggregate statewide data for comparison PA 3 Pennsylvania Patient Safety ROTEN PSRS Reporting System Organization Training Facili Event Detail by Harm Sc
61. Requested assistance fram quality improvement in conducting anahrsis of evenit 1 Mo actions necessary To be determined Other specify maximum 250 characters 47 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 18 Does event quality as JCAHO defined Sentinel Event Definitions C ves C No C Based on Harn Score selected no responze is needed C To be determined 19 If root cause analysis perfarmed select root causas select up ta 3 causes that contribute most to event other specify maximum 250 characters Based on Harm Score selected no response is needed No root cause analysis performed To be determined Other specify sit y l Other specify 8 20 Causal code Einthoven Classification Madel Medical Version Definitions m Based on Harm Score selected no response is needed C Mone Tobe determined I 21 Assessment of Additional Costs Incurred check all that apply C Based on Hann Score selected no response is needed C No additional cost O Patent discomfort or inconvenience L Additional laboratory testing or diagnostic imaging O Other additional diagnostic testing O Additional patient monitoring in current location 1 visit to Emergency depanrmeni Hospital admission L Transfer to more intensive level of care O increased length of stay C Minor surgery C Major surgery O System or processes de
62. S GUIDE INTRODUCTION Under no circumstances will the Authority release the details of specific event reports in a manner that allows a reporting facility to be identified e The Department of Health will have access to all reports of Serious Events Infrastructure Failures and Other events Although submitted reports will identify specific facilities they will not contain any identifiable information such as the names of individual healthcare Workers or patients e Each facility that submits reports to PA PSRS will have complete access to all of its own reports Each facility will also have access to aggregate data gathered from reports submitted by other facilities which could be useful for comparative purposes However no individual facility will be identifiable through the aggregate data reports MCare specifically protects from disclosure reports submitted to the Authority through PA PSRS Section 311 a of the Act states that any documents materials or information solely prepared or created for the purpose of complying with the Act s patient safety reporting requirements are confidential and shall not be discoverable or admissible as evidence in any civil or administrative action or proceeding HIPAA Concerns Under the Health Insurance Portability and Accountability Act HIPAA of 1996 PL 104 191 all healthcare providers and their business associates are responsible for protecting the confidentiality of protected health info
63. S CONC T E TNT 66 SVEV ASSES SINCE C OLO C n 67 EVENT AUDERET UT E 69 ROOT CAUSE ANALY SIS cocci et sh hs Ku CLIE ELEM CU LEID E RE LEE LEER Oe eed E Id 70 DATAGJANALYSEISIQ deni UN MM n NM NIE 73 VERSION 6 5 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE TABLE OF CONTENTS TIT EOE TOI P tees 73 ACCESSINGAVAILABLE REPORTS eaten set races tc ted e iee E aE aUa SO T EAEN RE OEE Eee ND d uli UE ED Dudes 74 birra e ANALYTICALREPOR TS A iei 75 Sunmar y Of oUm e REPOS OY T PE NITE TIT TT TET T TT T 75 HO score LOTS S aa E sp sets E E E T E E A OAE A AA N 76 HA COLE D TP E N E E E AANE NTA E E AE E A E MM Lf Eye Det PECORI ntn iim Um tuna ub ss uM 78 DDT TUT OW Op SOCIO POTIS eid nn RU EE E E mes 79 TOTS TV BUT RE BT TIPP ees igs 1 High Alert Medications and Steps in the Medication Process eese eese eene eene enn tenerent nnns 82 Medications Contributing to Risk for Fall eese esee en et tn nennen ttti nn et rn sets strane n ense stern nennen 83 TOCA S Red e a TO T Al enea TE EEEE E E T 84 Distribution of Potential Contributing Factors eee esee sees eene tn st ten et tn st ttne ernst rns tras etin stes strane ness rn nennen 5 VIRI P WEARS TII DO dp RT 86 PEARCTIN ORE ORT E 8
64. S Reportin system Organization Training Facili Medications Contributing To Risk For Fall Selection Criteria Report Style Report Submission Type Serious Event v Incident Event Date Current Year Gender All Age All Care Area All Regenerate Report Select New Criteria Choose New Report Return to Main Page File Edit Tools View Gallery Facility Medications Contributing To Risk For Fall 0 P Benzodiazepines e g valium Ativan 7 Pain medications opiates 7 Anticoagulants 14 Laxatives 795 m Diuretics r E Cardiac hypertensive medications 795 w Apnti seizure medications 29 Other 21 Select New Criteria Choose New Report Return to Main Page VERSION 6 5 83 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Details Related to Falls VERSION 6 5 This report is available to all hospitals reporting to PA PSRS For additional reports available to hospitals enrolled in the falls reporting program see Chapter 8 Falls Reporting Program Available either as a bar chart or table this report presents the responses to detailed questions about reports of patient falls Examples of these detailed questions include the following e Whether a falls risk assessment was completed e Whether a sitter was in place Whether the patient lost consciousness From the main report selection page select report type e g Serious Event Inci
65. a P O Box 706 des Commonwealth of Pennsylvania sre XWXEE Patient Safety Authority Tel 866 316 1070 ol free T Fax 610 567 1114 Training Manual and Users Guide Using the Pennsylvania Patient Safety Reporting System PA PSRS p PSRS Pennsylvania Patient Safety Reporting System Version 6 5 June 2015 Table of Contents INTRODUCTION Pc M s 1 PUR POS i l CORGANIZA TION EA A EE E EEE E AE EET E E E 2 BAI SCOPE OPP ASI OR horaina A A 3 SYSTEM CONFIDENTIALITY AND DATA ACCESSIBILITY ccccsssscccscssssssscccssccssssssccessccsssssscessesesssescessccssssssecesscesssssscessocesees 4 FIP AA CONCERN a duet daniele CLAU E ADEL Ei DEAL AAA EUIS 5 IMPACT OF PA PSRS ON REPORTING TO OTHER ORGANIZATIONS cccsssssscccccesssssscccesccssssssccesscsssssssseeseecesssssceesseesssstsseeseees 5 AACKNOWEEDGEMENTS2S desto sd NER LL LU Beata iE E 6 GEFIING SIARTED nido tede eic eec tesa desee eus MM E ML M UE ME I eC EI UAE 7 FE SHAT Bd ell tn 6 TIONS eer een ee ae cama En ee DL MM D IUE aU Se ne 7 CERRO a E A A M E Ee Se Se 7 oes en RM UU X m eee 8 CP Wer durs T s 10 CREATING AND G HANGING PASSWORDS itid enseho cas caso oo aa dt aee c pedo RO bg nouo ap aeree quet dim nad
66. ach falis ewernthype tnt inda presenbon strategy in place Patients without a prevertorstrategy indicaied were exciuced Information displayed across the top of the Falls Dashboard includes the total number of falls reported as Serious Events and Incidents the facility enrollment date for the Falls Reporting Program and the enrollment level Graphs and table displayed include Periodic Falls Rates see section on Falls Rates Reports Facility Level Patient Days Falls Rates Quartiles Three quality improvement tables Falls Risk Assessment Falls Details Falls Prevention Strategies in Place The Facility Level Patient Days Falls Rates Quartiles table shown below provides the ranking of an individual hospital compared to the state ranking of hospitals falls rates The quartiles are based on facility level patient days falls rates This report will not change when a falls tracking group or care area unit data is selected for the falls dashboard report Facility Level Patient Days Fall Rates Quartiles Your Hospitals Ranking 2nd Quartile for falls rate 3 167 falls per 1 000 patient days Q1 25 2 566 falls or fewer per 1 000 patient days Q2 50 4 014 falls or fewer per 1 000 patient days 03 75 5 967 falls or fewer per 1 000 patient days 04 100 19 066 falls or fewer per 1 000 patient days 118 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM The Falls Risk Asse
67. acilities fo work VERSION 6 5 114 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Facilities enrolled at the unit level are also able to calculate falls rates for individual Falls Tracking Groups See section on Falls Tracking Group Rates Reports Missing Data When a facility is missing utilization data for a given time period the charts will not have a trend line or bar chart for that time period and the table will be marked with a capital letter M to indicate Missing Data as illustrated in the examples below Facility Falls Rates Facility Falls Rates June 2012 to December 2012 June 2012 to December 2012 w Cn N 2012 Jun Jul Aug Sep Oct Nov Dec Number of Falls serious 4 4 1 and incident events Falls Per 1 000 Patient Days e e C b Cn ho Cn Go Facility Falls Rates Days wi Facility Falls Rate M NA missing data M missing data Falls Risk and Strategy Process Measure The Falls Risk Strategy Process Measure report may only be run in tabular format By default this report displays information as entered in PA PSRS reports for all falls i e Incidents and Serious Events for the most recent month of complete data This 2 X 3 table displays the total number of falls reported the number of patients assessed for falls risk and either identified or not identified at risk to fall and the number of patients in each category
68. al Human failures originating beyond the control and responsibility of the HEX OEX O Transfer of knowledge Protocols procedures O i O investigating organization Knowledge based behaviors Knowledge based errors The inability of an individual to apply existing knowledge to a novel S situation Rule based behaviors ee HKK Qualifications Incorrect fit between an individual s qualifications training or education HRQ and a particular task Verification Failures in the correct and complete assessment of a situation including HRV relevant conditions of the patient and materials to be used before starting the intervention Intervention Failures that result from faulty task planning Selecting the wrong protocol and or execution selecting the right protocol but carrying it out incorrectly Monitoring Failures during monitoring of process or patient status during or after HR intervention Skiltbased behaviors Do Se GUN Patient related factor Failures related to patient characteristics or conditions that influence PRF treatment and are beyond the control of staff Unclassifiable Failures that cannot be classified in any other category Source Battles JB Kaplan HS Van der Schaaf TW Shea CE The attributes of medical event reporting systems experience with a prototype medical event reporting system for transfusion medicine Arch Pathol Lab Med 1998 Mar 122 3 231 8 HRI M VERSION 6
69. an acceptable response for certain questions There are no event detail questions associated with reports of Infrastructure Failures Screen 1 e Select Other by checking the box next to this report type Click Definitions for help identifying the report type e Click Next Page to proceed to the next screen PA Pennsylvania Patient Safety rime remaining EEREZB id PSRS Reporting System Reset Timer Help Event Report Pes n don zen i 1 Recor Submsseon Ty pe Choose only one Next Page Cancel VERSION 6 5 50 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Screen 2 Questions 1 through 4 e Answer each question by selecting the appropriate check boxes or entering the information requested into the dialog boxes e For questions 3 and 4 you may use the response Not Applicable for Infrastructure Failures that do not affect particular patients e g power failure e Click Next Page when finished to proceed to the next screen B Pennsylvania Patient Safety ee 21 2015 PSRS 3X B ReporingSystem B3 0 Reset Timer Help Event Report 1 Report Submission Type Choose only one ein Senous Event Incident Infrastructure Failure 4 Other 2 How Was This Event Dscovered check ail that appi Witnessednmolved Report by pabent Report by famiy or visitors Report by staff member Report by resident fellow or stude
70. ar as shown below User Administration Falls Program Log Off As the Facility System Manager the selections available from your Navigation Bar are Main Page User Administration Add New User View Edit User Care Areas Add New Group Edit Delete Group Add Care Area VERSION 6 5 11 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE GETTING STARTED Edit Delete Care Area Falls Program Enrollment Options Resources New User Training Training Manual Online Education Program Memorandum Advanced Data Export Users Guide Root Cause Analysis Form Data Interface Specifications Pharmacy System Worksheet Anonymous Report forms and Brochures Manage Security Questions Log Off Creating and Changing Passwords As required for software hosted on Pennsylvania s computer network the system will prompt you to change your password every 60 days for security reasons Password Creation When a new user is created an email is sent with a link to a page to retrieve the User ID create a password following the rules below and setup the security challenge questions When a password is reset an email is sent with a link to a page to create a new password following the value requirements below When a password has expired a prompt to change the password following the new requirements will be issued If no security questions are yet defined the selection of and answers to three 3 different questions
71. are Availability and Reduction of Error MCARE Act Also available at http Awww pabulletin com secure data vol44 44 39 2041 html 3 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE INTRODUCTION context the word event is not to be confused with the MCare defined term Serious Event which is defined much more narrowly In developing PA PSRS the Patient Safety Authority established several underlying principles e PA PSRS must be comprehensive understandable and easy to use e PA PSRS must be user friendly and respectful of the limited resources available to reporting facilities e Once established PA PSRS should not be redundant duplicative or burdensome to reporting facilities e PA PSRS must support two way communications The PA PSRS program will not only receive reports from reporting facilities but will also provide feedback to facilities that they can use in their own patient safety and quality improvement activities For example facilities are able to generate statistical tables and graphs of their own data for internal use and analysis See Chapter 6 Data Analysis for samples Facilities can also export data from PA PSRS to perform customized analyses see Section 6 Data Analysis System Confidentiality and Data Accessibility VERSION 6 5 PA PSRS is a Web based application with several layers of security including Secure Socket Layer SSL encryption technology
72. automatic log off after 15 minutes of idle time on a single report input screen and intrusion detection systems To help ensure security the following steps are taken e Each user of the system must register once Each user is associated with a single reporting facility e All information transmitted from the facility to the PA PSRS application is encrypted using industry standard SSL technology e Users will be required to change their password every 60 days e PA PSRS resides on the Commonwealth s system and hence has all the protection that the Commonwealth has for other secure applications including intrusion detection systems The reports of Serious Events Incidents Infrastructure Failures and Other events you submit to PA PSRS are strictly confidential and will be available only to the parties and in the manner specified in MCare Data from the system will be accessible as follows e The Patient Safety Authority and its contractors will have access to all reports of Serious Events and Incidents Although submitted reports will identify specific facilities they will not contain any identifiable information such as the names of individual healthcare workers or patients While the Authority will produce analytical reports based on submitted data these reports will include only aggregate de identified data representing multiple institutions 4 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USER
73. blern Hone Te be determined Saf Factors Based on Hann Store selected no response is needed O use of foal siat Use of agency temporary or traveling staff CI Staff scheduling issues inadequate eyetem for cavering patient care insufficient staff Fatigue C Issue related to proficiency O issue related to impairment None Ta bie determined 34 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 e Patient Clas acteristics E Based on Harm Score selected no response is needed O Lack of palient compliancefadherence ls C Lack of patient understanding O Language barrier oO Lack of famihr menter cooperation None To be determined f Organizational Management C Based on Harm Score selected no response is needed C No 24 hour pharmacy inadequate bed availability Presence of boarder patientidifferent serite L efinitions Presence of observation patient Lack of policies and procedures Unclear or ambiguous policies and procedures Procedures not followed C None C To be determined g C Other please specify any additional information maximum 500 characters 17 Wehal Was Done To Remedy The Situation Or Reduce Its Likelihaad Far Recurrence check all that apply Based on Harm Score selected no response is needed C Talked with patientramibr C Arranged for support of staff member involve
74. by both its frequency and its severity The frequency or likelinood of reoccurrence is rated in four categories from frequent to remote while severity is rated from catastrophic to minor The significance of a report is determined by finding the intersection of these two ratings in the matrix shown below in Table 5 2 The number in the appropriate cell is the severity score The higher the score the more significant the report Table 5 2 Veterans Health Administration Severity Assessment Code SAC Matrix Probability of Severity reoccurrence Catastrophic Mejor Moderate Mer Rege 3 LOU Occasional a T E T Uncommon 2 1 L GNE NEM a a ee NE NN Source Garthwaite TL VHA National Patient Safety Improvement handbook 1050 1 Washington Administration Department of Veterans Affairs 2002 Jan 30 various p mms DC Veterans Health For example when reviewing a report of a blood transfusion error in which a patient is given blood of the wrong type you might rate such a report as remote in terms of its likelihood of reoccurrence but catastrophic in terms of its severity if it should reoccur Though this type of error happens very infrequently the results can be devastating often involving the death of the patient when such errors do occur Therefore this type of report a 3 is more likely to deserve a more thorough investigation and analysis than a report reflecting situations coded 1 In
75. ck Submit Report you will see the screen below which asks you to attest that the information in the report is accurate and complete and to confirm that you are ready to submit the report Press OK to submit the report Microsoft Internet Explorer This serious event will be reported to Ehe Patient Safety Authority and the PA Department of Health By submitting this report ou attest that the information provided is accurate and complete to the best of your knowledge Do you wish to submit this report at this time VERSION 6 5 37 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Once you submit your report you will see the following screen which confirms that your report has been received The report will be assigned a unique Report Number which you can record You will also have the option to print out a summary of the report you just submitted or to immediately begin to enter a new report PA 3 Pennsylvania Patient Safety Tuesday September 13 2005 Reportin system Organization Training Facili The submission process has been successfully completed This repart has been submitted ta the Patient Safety Authority In addition due ta the nature af the report a copy will also be sentto the PA Department of Health For your records the Report Identifier associated with this submission is 4951 1 Thank you What would vou like ta da next Print This Report
76. codon of Pont n aon af pir m gia ri rom F d Aet Raga dans Latus Fo Chus Frutas es F oa imp er ee ee s muasdes ey Pog Habra faders op peck ee Lala or piim Fo fea suem m carm maru ee i i dtu ar Pg tis Fi Ober eai CO lw maii Clm Dm n oe Pam Mae a a j O Beate lag Cac Asus ik Qaem 14 Hii eem Dems V hus RUM a ey MARET i ee GANE es MD Ga Se RR EU PU es ee ee oe RR Url LJ I Ir JEMEN VERSION 6 5 45 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE VERSION 6 5 EVENT REPORTS Screen 7 Follow up Questions Questions 16 22 In many cases you may not be able to answer with certainty the Follow up Questions at the time you are completing an initial report When this is the case provide answers that best represent your current understanding of the event You can amend the report or provide additional information for up to 90 days after submitting your initial report Later in this chapter we provide instructions on how to amend an existing report You may revise your responses to these questions after additional investigation ranging from simply discussing the event with the individual who reported it through your facility s internal reporting system all the way up to a formal root cause analysis or other investigative technique PA PSRS allows you to record and analyze the results of your own investigations a Tuesday September 13 2005 P Pennsylvania Patient Saf
77. creen This will open a copy of this Training Manual in a new browser window VERSION 6 5 23 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS PA3 Pennsylvania Patient Safety PSRS Reporting System F 16 2015 1 Rapo Submission Typ Charla fy ae _ Serious Event Definitions Incident Daofinitions Infrastructure Failure D feitons Otter Da fink Sarsous Event An event cccunnence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient The berm does not inchude an incident Remeni To be considered a serious event the event occurence or situation must meet all ol The criteria under Column A of all of the criberia under Column B Columna or Colum B a invobed the cmcal care ol a imohed the clinical cane of a patent in a medic a patent in a medical facity Resulted in the death of the s Comp pabeni salety a Racdiedinan unadtcpated iegury requimg adddionusd healthcare services Incident An event occurrence or situation involving the clinical care of a patient in a medical Facility which could have injured the patient but did mot either cause an unanticipated injury or require the delivery of additional health care services to the patient The tenn does mot include a serious event Rame
78. d o Discussed tha eventwrh the involved healthcare worker Discussion with staff of unsafe practices Physically removed equipment or supplies O Stati orientation process Education or training of staff Documentation procedures C Modified staffing pattern or workflow Referred issue to another department identity oO Rietened issue to medical leadership or administrative leadership go Requested assistance fram quality improvement in conducting anahrsis of evenit 1 Mo actions necessary To be determined Other specify maximum 250 characters 35 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 18 Does event quality as JCAHO defined Sentinel Event Definitions C ves C No C Based on Harn Score selected no responze is needed C To be determined 19 If root cause analysis perfarmed select root causas select up ta 3 causes that contribute mast lo event father specit maximum 250 characters Based on Harm Score selected no response is needed No root cause analysis performed To be determined Mj Other specify sit Oooo M Other specify 8 20 Causal cade Einthoven Classification Model Medical Version Definitions L3 Based on Harm Score selected no response is needed None Tobe determined I 21 Assessment of Additional Costs Incurred check all that apply C Based on Hann Score selecte
79. d no response is needed C No additional cost O Patent discomfort or inconvenience L Additional laboratory testing or diagnostic imaging O Other additional diagnostic testing O Additional patient monitoring in current location 1 visit to Emergency depanrmeni Hospital admission L Transfer to more intensive level of care O increased length of stay C Minor surgery CI Major surgery O System or processes delay care to a patient C To be determined O ther specify maximum 250 characters 22 her Comments maximum 250 characters Subma Repori e Answer these questions by following the directions on the screen using the check boxes and menus provided e When you are finished with this screen you may click on Submit Report When you click Submit Report you are filing a report as defined by MCare 36 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS If the report is a Serious Event it is submitted to the Patient Safety Authority and the Department of Health If the report is an Incident it is submitted to the Patient Safety Authority If the report is an Infrastructure Failure or Other event it is submitted to the Department of Health If you fail to click Submit Report from this screen or if you stop entering information at any point before reaching this screen the report will not be submitted and your data will not be stored in PA PSRS When you cli
80. d atRiskotFall Risk of Fall Falls Preceution s in Place Prot History of alis in the past 12 months May Falls Detalls 2012 Requires Visual or Top 3 alis Event Types UM assistance heanng Duzmess AS bOBtyf alls Rates Ste Mate M missing data Utpressed frein chili impairment of vertigo elwninatior Pee Group Rate i Foni fon Mane a r E Cher Unknown apecily ES The marmber of falls deli tepreserds fms enpues or emch galeri charadterslic No Urkriswn anc bint resoorsans were seduced Facility Level Patient Days Fall Rates Quartiles Pernt hotel inciudes all patentee fort m tesenttype Patents could hine had multiple alls decals iraibe four Hospitals Rang Znd Cuvariile Falis Prevention 5trategles In Place Tas falls abe 3 167 falls ger 1000 patient days 21 258 2 83 falis or fewer ner 1 000 puien dr Hourly or Equipment Used ide F EP i Top J I als Lwent Tyges Risk sad Fara ane cn eni pog M uiri high ye boila Eu imr Total Q2 50 4 034 falls orfewer per f DOO patent days Camin nr Prese Bed lined miis up fala m i 1 Mentre Caueation cuamaunaa Saem Clothing or Chair pes Puce Place Pabente Gass 6967 falis arfewer per 1 000 patient drys Oa 15 006 falls oriewer per 1 000 patient cays Found cn fir VERSION 6 5 Cher LImiknengn aperi Ambulating n ait Hian paraita ould hare hard mpe pimenbosieges in place Heni jota represents all patienisfore
81. dent By selecting Additional Criteria you can modify the report by event date gender or age of affected patients harm score cluster or care area Report Style Char v Report Submission Type Serious Event M Incident Ewent Date Current Year Gender All Age All Harm Score All Care Area All Regenerate Report Select Mew Criteria Choose New Report Return to Main Page Facility Details Related to Falls Patient lost consciousness 4 Patient unable to rise from chair without assistance amp Dizziness or vertigo amp Fall precaution protocol in place 10 Stier in place 12 Fal risk assessment completed 13 At the tme of last assessment was patient determined at risk 14 Does patient have recent history of visual impairment 5 Does patient have recent history of hearing impairment 16 Does patient have prior history of fall in the past 12 months Select New Criteria Choose New Report Return to Main Page 84 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Distribution of Potential Contributing Factors VERSION 6 5 This report presents either as a pie chart or table the distribution of factors contributing to submitted reports These factors are based on the following categories Team factors Work environment Task factors Staff factors Patient characteristics Organizational Management factors Other The default setting for this report i
82. dment Humber Retrieve Report n Go To Main Page To find reports older than 90 days use the search function described under Searching Reports in Chapter 6 Data Analysis Amending a Submitted Report After you submit a report to PA PSRS the report may be amended for up to 90 days It may be appropriate to amend reports to correct details that upon further investigation turned out to be incorrect to augment reports with the results of an investigation or root cause analysis or to update reports as circumstances change You can see how many days remain to amend a report from the Main Page refer to the column Days Remaining to Amend After a period of 90 days from original submission each report is locked down in the system and may no longer be amended Such reports may still be viewed and printed To amend a submitted report follow these steps 1 From the Main Page enter the Report ID in the dialog box in the upper right of your screen labeled Selected Report ID Rather than type in the Report ID clicking on an ID number in the first column will enter it for you PA g Pennsylvania Patient Safety Wednesday September 14 2005 PSRS Reporting System Organization Training Facili Help Pian HNCLCHECTIOENUCLIONNC TI View l Date Range 09 01 2005 to 09 14 2005 nei ticn Completed Report Selected Report ID 49520 Showing 1 20 of 22 Total Records Print Amendments to Report ID TBD Report Type CareAr
83. dual who submitted the original report date and time of last update where applicable and the User ID of the individual who made the latest amendment In addition if any field on the report has been marked To Be Determined a statement indicating this is displayed as a reminder to the facility 61 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS PA Pennsylvania Patient Safety PSRS Reporting System Report ID 50521 02 View Amendments to Report Submitted On 9 21 2005 11 22H By pso Last Updated On 9 22 2005 09 12H By pso This report has one or more fields marked To Be Determined Lancaster Orthopedic s LLC Training Facility Report Detail Summary Full 1 Report Submission Type x Incident 4 How Was This Event Discovered check all that apply x Report by family or visitors 3 Gender Of Affected Patient x Female 4 Age Of Affected Patient 40 years 5 Location Where Event Occurred Chem Dependency Unit LE Vito WF Aelnniccinan dan FE OW Aah ates Cie cdo 10723 nN E Report History You can also use PA PSRS to generate a report history A report history is essentially a report that shows you what changes have been made to an event report since it was originally submitted as well as who made each change This feature will be more significant for facilities where the PSO has authorized multiple individuals to submit reports to PA
84. e appropriate check boxes or entering the information requested into the dialog boxes e For questions 3 and 4 you may use the response Not Applicable for Infrastructure Failures that do not affect particular patients e g power failure e Click Next Page when finished to proceed to the next screen P Pennsylvania Patient Safety I 21 2015 PSRS Reporting System 14 24 Event Report 1 Report Submission Type Choose only one Defnibons Senous Event Incident V Infrastructure Failure Other 2 How Was This Event Discovered check ail that apiy _ Witnessecinvoived Report by pabent Report by family or visitors L Report by staff member Report by resident fellow or student Assessment after event C Review of record or chart 3 Gender Of Affected Patent check one Male Female Not applicable check for events involving zero of Multiple patents 4 Age Of Affected Patient Equal or greater than 2 years years Under 2 years months Under one month days Not applicable check for events irvoing zero or multiple patents Next Page Iop of Page Cancel VERSION 6 5 40 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 Screen 3 Questions 5 through 8 Answer each question by selecting the appropriate check boxes entering the information requested into the dialog boxes or using the pull down menus For questions 6
85. e steps 1 From the Main Page enter the Report ID in the dialog box in the upper right of your screen labeled Selected Report ID Rather than type in the Report ID clicking on a Report ID number in the left column will enter it for you 2 Click on View Print in the Navigation Bar 3 Click on Report Amendments in the pop up menu 4 The selected report opens in a new browser window When you are done viewing the report simply close the browser window PA Pennsylvania Patient Safety Tiesday Gententberd d 2005 Reportin system Organization Training Facili Help Amendments to Report 49208 Event Details for Event M Fall risk assessment completed Initial value s Changed to Mo by Smith Jackie on 8 3 2065 9 51 06 AM M At the time of last assessment was patient determined at risk Initial value Changed to Mo by Smith Jackie on 8 8 2005 8 51 05 An OQ Level of injury as a result of the fall Initial value Changed to Minar resulted in application af a dressing ice cleaning af a wound limb elevation ar tapical medication by Smith Jackie on G 9 2005 9 51 06 Ant Print List of Amendments Main Page VERSION 6 5 63 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Blank Forms You can print copies of blank forms that contain all of the questions and possible selections for PA PSRS event reports These may be useful as checklists
86. ea Report qm PUN m Days Remaining Event Date amp Time Date amp Time Score to Amend Report Submitted T Td Tt T T T Tt T TY 49530 Infrastructure Test Care Area 11 X Other Infrastructure Failure A 8g 09 12 2005 22 22 9 13 2005 15 04H 49520 Infrastructure Test Care A rea11 X R Emergency Services Response A 89 09 12 2005 11 11 9 13 2005 15 02H 49511 Serious Test Care Area 11 A Medication error E 89 09 12 2005 22 22 9 13 2005 14 47H 49469 Incident Test Care Area 12 E Error related to Procedure C 89 08 1 3 2005 Unknown 9 13 2005 13 34H Treatment Test 2 Click on Event Report in the Navigation Bar 3 Click on Amend Event Report in the pop up menu 4 Move the cursor through the questions just as you would when originally submitting a report until you reach the question you want to amend Make the necessary corrections VERSION 6 5 60 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS 22 Other Comments maximum 250 characters Submit Report Top of Page Cancel Go To Questions 1 4 5 8 Event Details 9 13 14 15 16 22 When you have made all the changes you wish to save your amended version of this report you must go to the last page and click on the hyperlink that reads Submit Report Otherwise your changes will not be saved Please note that an Amended Report will be assigned a modified Report Number to distinguish it from the original r
87. ed Patient Days provides a facility level falls rate that combines inpatient and outpatient care areas The Falls Rates Report Inpatient vs Outpatient Care Areas is shown below VERSION 6 5 113 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Facility Falls Rates June 2012 to December 2012 Falls Per 1 000 Patient Encounters Emergency Outpstient Radiology Rehabilitation Department Clinics Services Services E Facility Falls Rate for Inpatients MS Facility Falls Rate for Outpatients A trend line facility falls rates report based on adjusted patient days with peer group periodic falls rate comparison data is shown below Facility Falls Rates vs Peer Group Facility Falls Rates June 2012 to August 2012 Peer Group Acute Care Hospitals over 300 beds Falls Per 1 000 Adjusted Patic Jun Jul Aug M9942 mee Facility Falls Rate Peer Group Periodic Falls Rate Peer Group PeriodicFalls aan Peel Group PeriodicFalls Rate Upper ConfidenceLevel Rate Lower Confidence Level M missing data A maximum of 13 facilities are included in the comparison group calculation Each time period is calculated separately and it s possible that each time period has a different number of facilities that are included in the comparison group calculation The comparison group calculation must have at least 5 f
88. ed antinori ented REL LOU poU 20 Preu ASCO OONOSHONS sis isis dete edite E tid Cel iat eerie Aie obo E Hate ode DIO ULL Lud UU 20 REPORT SUBMISSION INCIDENTS AND SERIOUS EVENTS ccccccssssssscccsccsssssscccscccssssssccesccssssssceessecssssssesssecssssssseseseeessssasees 23 REPORT SUBMISSION INFRASTRUCTURE FAILURE cccsssssscccscesssssssccesccssssscccesccsssssacesesccssssssecescesssssscesecesesssssseceseeessaaes 39 REPORT SUBMISSION OTHER EVENTS eati dovte tin SPI o Ud vam ads i con dus eus A sesso UMa o cuce edes tnam ule ERU LMU ELI D c eL DL dude Rud 50 MANAGING SUBMITTED REPORTS 3 5 6e ot otto etude eure a ad adeo condat v ened escape veas o ul ocu ode a lusM RU LdUV LN I ceL AD dauaccuacsraeed 58 AMENDINGA SUBMITTED REPORT MERE TT a a a a 60 WIEWING AND PRINTING REPORTS a epe docte satu eden a te a a a 61 REPORT EUS POR RR TRU TR C nats 62 BLANK FORMS reece IM EI d M IAM LEAL cM EMI IM EE MM EM LIC M MM LIC MM E MM EDI IIT M MEE EM PEDAL 64 ANONYMOUS REPORTS 8h testi cette Ais tout sot ete dil epe sudeste edu A M ELE tte ls 64 RESOURCES 2 coca e UEM D A AREE uA UL D AA Ae ERA Lu MD d AA CE A Era 64 RE PORT CODING ec 65 CLASSIFICATION S YSTEMS iecit ot en i oA e OE t o PDA VER ae E Eo ono Le bec oer M onc A eae 65 REPORTSESVBEIDI S ee ce re uui EM MM e ML AS tA o in EM M A MC MM RD Oa 65 FA OTI
89. ed issue to another department identity oO Rietened issue to medical leadership or administrative leadership go Requested assistance fram quality improvement in conducting anahrsis of evenit 1 Mo actions necessary To be determined Other specify maximum 250 characters 56 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS 18 Does event quality ag a JCAHO defined Sentinel Event Definitions C ves C No C Based on Harn Score selected no responze is needed C To be determined 19 If root cause analysis performed select rool causes select up ta 3 causes that contribute most to event other specify maximum 250 characters C Based on Harm Score selected no response is needed No root cause analysis performed To be determined Do M Other specity sit 20 Causal code Einthoyen Classification Model Medical Versiony Definirions O Based on Hann Score selected no response is needed C Mone Tobe determined he 21 Assessment of Additional Costs Incurred check all that apply C Based on Hann Score selected no response is needed C No additional cost O Patent discomfort or inconvenience L Additional laboratory testing or diagnostic imaging O Other additional diagnostic testing O Additional patient monitoring in current location 1 visit to Emergency depanrmeni C Hospital admission Cl Transfer to more intensive level of care O increased length
90. ed or contributed to the event e Click Next Page when finished VERSION 6 5 53 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Pennaytvorio Patient Sofety Tum Coupe 2 X74 PSRS Rey LI L Mah 1T m7ran LA Cold Frag T cnt mr ar m ur eee 0 Yu l ys C Oden A Timb Mouth T Ppi Comed a Cubed t he Loma check ad oar apis BE T TT Ci Matau getes he dang nira Tua Colnghileq ma Pd U Pe Other Fem Speech pa oO Wlectrssds beak record E FK sr compere of HE Fa Capim pai ode entry CPOU creme Fi Pms ete Poe Dera manda alm a rocard MA Ced bona n 6 pe qnem me Fae Conci drones na COO meee Pot Wam F a Otter Pome pci en oo oO ee Foa kmi pa ryviom v turam rie deme o g beani em mucrone rmi mtm intem aat pT preter c Lewer el mater prem LIT m helm arnb and pale cr rectos Seber ipii na mites kiiy pte h ad comam dias cem FATT Poe OB Frw Drs f B HIT Comrisdeq F actes check adi foa appe F a Lem or dior ol dts M amp fyrem mura or mores da Dat boni eot math palet Foa mage told rti orm on wt mago union gacnet a cese wet reeds Tf manto bews progrummang cd an og bomen a ngpo dert Po Che Fhar Spec oo ao F oa Hedra ber atm e q mboi pin emnt fer usn amp Cam eatery ow iae OF qoom or rincon lame palet wrong promis wes drag weseq dee Pe himaan dephey or pipea 0 fet men color of fet nc aon
91. eeesueceseecsaseeeeseaseessesesseenseeesees 101 Amending Facility level Utilization Data eee esee rnn tenerent ttn streiten serine resins senten 102 SUBMITTING FALLS REPORT C S 103 PANEN IOUS ET c ede 103 DUELO IB U 105 eee 106 COMMIT AOC BUR TNR m 108 TS CP OT carci NE es beset vce ess ew Aaa bo sac rts esc RS ACen 110 TOGUNCRTOS Te COTA Sc ase on EATA S TUE ARN AURA MDURD MUI IM ANE os UP Eu ud Rd atu Ber CU e Tu uma NOE USC BC AE 111 IVES SHINO TD OIG N 115 Falls Riskand Strategy Process Mesur ierat teet Rhet UL GI E UL OI HEU OG HUC UN GER REL aaeain idiarena aeaiia 115 OLIN G DLOKS 1416161 0 assem Uv SINE aS IER rM Face EUH Pe ene I RUN E tI MV ee EROR C ID eR RIA CSS RPSL I y ne eter US 117 Falls Tracking Groups Rates RepOFPIy acecsxnscec ncc CIEN IUE IIR UNA URSUS STERCUS EUE SU EU S Ex EN CER re UH p XN A SE UVS 120 Tar on tdt DUE ose aiti ER S eae nanan a aeons aa IU ENS 121 BEANE TORNI eec c 123 SERIOUS EVENT ANONYMOUS REPORT FORM jecscsccsscnstesesassecseossssasnaananceed S SERES PO apA LASS Y edna isaten niv I KR UEebS Ore a GR UP E HRS EEUU Ru ERR ODE SU DS 123 EVENT DETAIL QUESTIONS SERIOUS EVENTS AND INCIDENTS sscssssssesscescc
92. eport see Report History later in this Chapter for details Viewing and Printing Reports VERSION 6 5 You may view or print an event report at any time after it has been submitted to PA PSRS Please be careful however about the security protections you put in place within your own facility regarding printed reports Since the information you submit to PA PSRS is confidential and sensitive consider how frequently you want to create printed versions of your PA PSRS reports Be sure to treat any printouts with the appropriate level of security To view or print a report e From the Main Page enter the Report ID in the dialog box in the upper right of your screen labeled Selected Report ID Rather than type in the Report ID clicking on a Report ID number in the left column will enter it for you e Click on View Print in the Navigation Bar e Click on either view or print in the pop up menu e By default the system will present a summary version of the report for viewing or printing In a summary view only items that were entered or checked will be shown e Alternately clicking Full View will present the entire report including all the items and check boxes that were not used in the report Notice in the screen shot below when viewing or printing a report the information displayed includes the Report ID current amendment number where applicable the original submission date and time the User ID of the indivi
93. eport ID Harm Days Remaining Date amp Time Report ID TBD Report Type CareArea Event Type Scorn 7a Pea J Event Date amp Time Report Submitted TL T TY Td T TY T4 TL T4 49530 Infrastructure Test Care Area 11 X Other Infrastructure Failure A 89 09 12 2005 22 22 8 1 3 2005 15 04H 49520 Infrastructure Test Care Area 11 R Emergency Services Response A 89 09 12 2005 11 11 9 13 2005 15 02H 49511 Serious Test Care Area 11 A Medication error E 89 09 12 2005 22 22 9 13 2005 14 47H 49469 Incident Test Care Area 12 E Error related to Procedure C 89 09 1 3 2005 Unknown 9 13 2005 13 34H Treatment Test Note the blue horizontal Navigation Bar on your screen that looks like the one shown below Main Page Utilization View Print Blank Forms Analytical Data Tools Resources Log Off Data This Navigation Bar s buttons or selections are used to move between the different system functions You use the Navigation Bar by positioning your cursor over your selection This will initiate a pop up menu of possible selections under that heading If you are a PA PSRS User positioning your mouse over Event Report in the Navigation Bar brings up a menu with three selections Create New Event Report Amend Event Report or Retrieve Event Report By Report ID To perform these functions simply click on your selection If you are a Read only user positioning your mouse over Event Report in the Navigation Bar brings up a me
94. er of affected patients Care area Harm Score category Event type adverse drug reaction fall etc After selecting the criteria for the reports you wish to retrieve click on Generate Report in the lower right hand corner of the page The resulting data set will be displayed in a format similar to that used in managing your current reports see Chapter 2 SEULE PI lm gt 4 ele at You can download data elements from reports you have submitted to PA PSRS using the Export Data and the Advanced Data Export function The Export Data function will create a comma delimited file containing key report elements which can then be imported to Microsoft Excel or another spreadsheet program To use this feature take the following steps 1 Select Analytical Data Tools from the menu bar on the main screen then select Export Data This will take you to the screen shown below PAS Pennsylvania Patient Safety Wechasday Senlernter 14 200 Reportin system Organization Training Facili Export Data This utility will export a list af submitted reports to a text file suitable for import inta a database or Excel spreadsheet nate Date ranges are limited ta 31 day intervals Please enter the criteria Export data based on 9 Event Date Submit Date Start Date HE em mud danny b End Date HE em mud danny i50 To Main Page VERSION 6 5 88 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING M
95. ety Time remaining EEEEEZN PSRS Reporting System Reset Tun Help nme Event Report 16 Potental Contnibubng Factors check all tha apply Fi 4 Team Factors Based on Harm Score selected no response is needed Communication problem between providers Change of serice same care area Cross coverage situabon Shift change rsa rar e 2 Unplanned workload increase Holiday None L To be determined p T b Work Erri onnment Based on Harm Score selected no response is needed Oistractions interruppons Limited access to patient informaton C Poor lighting LJ High noise level inadequate equipment availability i C Equipment malfunction P 4 Mone To be determined Task Factors U Based on Harm Score Selected no response is needed Training issues Emergency situabon LJ Inexperienced staff Inadequate resident upemnnsion Cardiacirespiratory arrest situation Order entry ystern problem None C To be determined d Staff Factors Based on Harm Score selected no response is needed Use of float stat Use of agency temporary or traveling staff Staff scheduling issues r 1 ma inadequate y tem for covering patient care Imsufficient stan a Fatgue Issue related to proficiency I sue related lo impairment p 7 P iu LJ L Mone To be determined 46 JUNE 2015 PEN
96. event occurred that contributed t os resulted in death Note Modified from National Coordinating Counc for Medication Error Reduccion amd Prevention NCC MERFI 11 Likelihood Of Event Recurrence Definitions 12 Severity OF Effect Resulting From Recurrence Of Event _ Definitions Next Page Top of Page Cancel Return to Questions 1 4 5 8 VERSION 6 5 29 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Screen 5 Health IT Question 13 e Question 13 asks you whether Health IT caused or contributed to the event e Click Next Page when finished PA g Pennsylvania Patient Safety y Tuesday October 21 2014 inimi Reporting System c Time remaining IM Reset Time Help Event Report Organization Memorial Hospital Health IT Questions 13 Did Health IT cause or contribute to this event Yes No Unknown Next Page Topof Page Cancel Return to Questions 1 4 5 8 Event Details 9 12 Sone suemeegd va fs Teor sysiem i8 orctected order sooicebe State and Federal law and shal only be used or Gsciosed m accordance mth those same laws 01 e 2004 Pencsyvene Patent Safety Authonty Al nghi reserved If Yes is selected a series of follow up questions will be presented The follow up questions record information specifically related to events where health IT was indicated as a contributing factor The health IT follow up questions include the follo
97. fol Epidural or intrathecal medications Dialysis solutions Colchicine injection Chloral hydrate Chemotherapeutic agent Cardioplegic solutions Benzodiazepine 9 File Edit Tools View Gallery Facility Steps in the Medication Process Patient Factors 14 Prescribing 14 Monitoring 14 Transcription Order Processing 14 Preparation Dispensing 19 Administration 24 Prescribing 1496 Transcription Order Processing 14 Preparation Dispensing 1996 Administration 24 Monitoring 14 Patient Factors 1496 Select New Criteria Choose New Report Return to Main Page 82 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Medications Contributing to Risk for Fall This report presents either as a series of pie charts or tables the distribution of medications e g anti seizure diuretics etc associated with submitted reports of patient falls This report is available to all hospitals reporting to PA PSRS For additional reports available to hospitals enrolled in the falls reporting program see Chapter 8 From the main report selection page you can select report type e g Serious Event Incident By selecting Additional Criteria you can modify the report by event date gender or age of affected patients or care area PA g Pennsylvania Patient Safety Wednesday September 14 2005 PS R
98. following configurable options Report Style Chart default Tabular Time Format Time series i e trend line default Cross section i e bar chart Comparison Group see section on Benchmarking following this section None default Peer group periodic falls rate State group periodic falls rate Peer group aggregate falls rate State group aggregate falls rate FALLS RATES REPORTS available for unit level enrolled hospitals only include the following additional configurable options Rate Calculation Patient days used to calculate inpatient falls rate default Patient encounters used to calculate outpatient falls rate Adjusted patient days combined patient days and encounters used to calculate facility falls rate Level Facility default Unit Individual Unit All falls tracking groups e g general medical surgical critical care default Individual falls tracking group Individual units within a falls tracking group The screenshot below shows the configurable options for facility level enrolled hospitals Criteria for Falls Rates Report 1 Report Submission Tipe Incident Fas reports dau bs Falls with Harm Serious Events on Ta see all Falls seed Incident 2 Comparison Grom Peer Goup Falls Rate 3 Report Format amp Trend Line Bar Chart Tabular 4 Periodicity 9 Maori Quanteity Yearly 5 Fire Frame From Monty Jul Year 2012 To Monti Jul Year 2012 Generate Report
99. ient VERSION 6 5 96 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM The definition of falls includes e Assisted falls in which a caregiver sees a patient about to fall and intervenes lowering them to a bed or floor e Therapeutic falls in which a patient falls during a physical therapy session with a caregiver present specifically to catch the patient in case of a fall e Physiologic falls in which a patient falls as a result of a seizure or syncope The definition excludes failures to rise in which a patient attempts but fails to rise from a sitting or reclining position Falls with harm Any fall that requires more than first aid care Treatment beyond first aid care includes a laceration that requires physician intervention e g sutures more serious injury e g fracture or death This definition does not include the use of steri strips Patient Days A house wide census conducted and recorded each day that counts the number of occupied beds in each unit i e Care Areas defined in PA PSRS The daily census should be performed at the same time of day at a time decided by the facility The daily census should INCLUDE all occupied beds and EXCLUDE unoccupied beds A bed is considered occupied if a patient is assigned to that bed at the time the census is conducted Patient Encounters A count of the total number of patients who receive services for that day in outpa
100. il 23 2015 check all uncheck all 1 Report Submission Type 13 Did Health IT Cause or Contribute to this Event 2 How Was This Event Discovered 14 Recommendations For System Improvement 3 Gender Of Affected Patient 15 Disposition Of Event 4 Age Of Affected Patient 16 Potential Contributing Factors 5 Location Where Event Occurred 17 What Was Done To Remedy The Situation 6 Date Of Admission Or Date Of Ambulatory Encounter 18 Does Event Qualify As 4 JCAHO Defined Sentinel Event T Event Date And Time 19 If Root Cause Analysis Performed Select Root Causes 8 Event Type 20 Causal Code 9 Describe The Event 21 Assessment Of Additional Costs Incurred 10 Harm Score 22 Other Comments 11 Likelihood Of Event Recurrence All Event Detail Questions 12 Severity Of Effect Resulting From Recurrence Of Event Go To Next Page Standard Data Export Main Page In addition to selecting which data elements to export you must select a date range You have the option of choosing either all reports which were submitted to PA PSRS during that particular date range or all reports where the event date falls within the date range Regardless of the date type selected a facility may request up to 6 months worth of data at one time If the date range selected spans more than 31 days the data is separated over multiple files based on month For example if the user selects the date range January 15 March 15 three files wi
101. ionalTherapy Hehab Occ Therapy Hehabilitation Services OP PT Hehab Phys Therapy Hehabilitation Services OutpatientChemotherapy O P Oncology Clinic Outpatient Clinics To view a history of your enrollment choices including the date time and person who made the changes select the Show History button at the bottom of the enrollment screen History Display Tip to group by an individual column drag it here Field Name Previous Value New Value Updated By Updated On Enrollment status Not tracking Facility level tracking fsm_rhosp 1 23 2012 11 10 05 AM Enrollment status Facility level tracking Not tracking fsm_rhosp 1 23 2012 11 12 33 AM Enrollment status Not tracking Unit level tracking fsm_rhosp 1 23 2012 11 14 58 AM Enrollment status Unit level tracking Facility level tracking fsm_rhosp 1 23 2012 11 25 35 AM Enrollment status Facility level tracking Unit level tracking fsm_rhosp 1 23 2012 2 10 11 PM The Falls Reporting Program uses the standardized falls definitions adopted by the Pennsylvania Patient Safety Authority s Authority Southeast Regional Falls Reporting Initiative and consistent with the National Quality Forum endorsed National Database of Nursing Quality Indicators NDNOI patient fall measures Your participation in the Falls Reporting Program requires adherence to these definitions Fall any unplanned descent to the floor or other horizontal surface such as a chair or table with or without injury to the pat
102. irthing Centers BCs and Abortion Facilities ABFs will have this question auto filled to outpatient and will not be visible Screens 3a f Detailed Questions e The next questions you see will depend on what Event Type you chose on the previous screen For example if you selected Medication Error this screen will ask you about the drug the dose the route of administration and other factors associated with medication errors On the other hand if you selected Fall you would see a screen with detailed questions relating to patient falls There are updates to two existing falls detail related VERSION 6 5 27 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS questions and three new falls detail related questions For complete instructions for Fall Event reporting please read Chapter 8 Falls Reporting Program For complete details of all Detailed Questions screens please refer to Appendix AJ e f you selected an event type that has no detailed questions such as Complications of a Procedure Treatment or Test the system will skip this screen e Click Next Page when finished Screen 4 Event Outcome Questions 9 12 e This screen asks questions about the outcome of the event In Question 9 you are asked to describe the event When doing so it may be helpful to start with the description the healthcare worker used when first reporting the event within your facilit
103. items of general interest such as upcoming training sessions and the introduction of system improvements and enhancements Some correspondence is in the form of program memoranda Program Memoranda can be located within PA PSRS under the Resources tab Five program memoranda are included in Appendix C of this manual Help Desk If you encounter any problems or difficulties using the PA PSRS system first refer to this Manual to see if the task you are trying to perform is addressed The Manual is available online at the PA PSRS website http www papsrs state pa us You will need to log onto the system to access the Manual The Manual will periodically be updated by issuing Program Memoranda to reflect incremental changes to the system If the Manual does not address your problem or question contact the PA PSRS Help Desk to answer questions regarding Incidents or Serious Events during business hours 9 00 a m 5 00 p m Monday Friday exclusive of holidays via toll free telephone 866 316 1070 Fax 610 567 1114 or e mail Support_papsrs pa gov For questions about Infrastructure Failures please contact the DOH surveyor for your facility Your surveyor may also be able to assist you with questions regarding Serious Events Please note that the Help Desk will not be able to advise you on whether to classify individual reports as Serious Events Incidents Infrastructure Failures or Other events See Frequently Asked Questions in
104. ity System Manager click on Care Areas in the Navigation Bar 2 Click on Add Care Area in the pop up menu 3 Inthe first dialog box see screen below enter the first location you wish to identify in your facility e g 3 West 4 Inthe second dialog box if applicable you can select a predefined care area group Specifics of defining Care Area groups appears later in the chapter 5 Inthe third dialog box select the location type for that care area from the drop down menu e g Psychiatric Unit All Ages 6 Click Save PA Pennsylvania Patient Safety P 5 R S Reportin System Tuesday September 13 2005 Help A O Edit Delete Care Area Care Area Name Gead 3west S Group Name West Share Facilities Care Area Type Required Psychiatric Unit All Ages v wiew Print ETCEETHETR Repeat these steps for each care area you wish to define in your facility While this may take some time especially for larger facilities itis something you only need to do once However it will VERSION 6 5 16 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FACILITY MANAGEMENT save you time in the long run and will greatly enhance the usefulness of the analyses you can generate with PA PSRS in the future Editing Care Areas Editing care area names or care area types will have an effect on analytic reports Changing the name of a care area will result in historical
105. lay care to a patient C To be determined O Other specify maximum 250 characters 22 her Comments maximum 250 characters Subm a Repori e Answer these questions by following the directions on the screen using the check boxes and menus provided e When you are finished with this screen you may click on Submit Report When you click Submit Report you are filing a report as defined by MCare 48 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 If the report is a Serious Event it is submitted to the Patient Safety Authority and the Department of Health If the report is an Incident it is submitted to the Patient Safety Authority If the report is an Infrastructure Failure or Other event it is submitted to the Department of Health If you fail to click Submit Report from this screen or if you stop entering information at any point before reaching this screen the report will not be submitted and your data will not be stored in PA PSRS When you do click Submit Report you will see the screen shown below which asks you to confirm that you are ready to submit the report Microsoft Internet Explorer This Infrastructure Failure event will be reported to the PA Department of Health By submitting this report you attest that Ehe information provided is accurate and complete to the best of your knowledge Do vau wish ka submit this report at
106. lications of care Many adverse events are unpreventable complications of care While this is true MCare is not limited to preventable adverse events or medical errors It encompasses patient safety more broadly The issue of whether or not an event is unanticipated is complex Please see PA PSRS Program Memorandum No 2004 03 Clarification Regarding Reportable Occurrences in Appendix C Does the existence of a code in the event type taxonomy imply that this type of event is always reportable under MCare No the decision about whether such cases are reportable is context specific and depends on the details of each case Are all questions required to be answered for all types of reports i e Serious Events Incidents and Infrastructure Failures For Serious Events and Infrastructure Failures all questions require a response However because MCare requires that Serious Events be reported within 24 hours of confirmation in some cases you may have insufficient information to answer all questions at the time you are submitting a report In these cases you will have the option to select To be determined as the response for the initial report submission When doing so it is expected that you will amend the report before the 90 day amendment period expires In addition for certain questions related to Serious Events with lower levels of harm score as determined in Question 10 you will be able to check the box labeled Based on harm
107. lization data entered for that unit will be included in calculations for historical aggregate group event rates e g facility level falls rates Example The Inpatient Psychiatric nursing unit 3 East has been permanently closed The FSM deletes the care area in PA PSRS on August 31 At the end of the year a report of events occurring from January to December for the Inpatient Psychiatric care area type will include any event reports or other information entered into PA PSRS for 3 East prior to August 31 Combining Care Areas VERSION 6 5 When combining care areas it is suggested to delete both existing care areas and create a new care area with a new name If one of the care area names is changed and one is deleted the new care area will contain events reported on the unit that changed names but it will not include events that occurred on the deleted unit 17 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FACILITY MANAGEMENT Care Area Group Administration Under the menu item Care Areas the Add New Group and Edit Delete Group items provide an option for facilities to specify care areas that can be grouped together for analytical reporting One use for this feature is for a multi facility system operating under a single license to group care areas by facility for analytical reports This would allow you to generate reports by facility without reviewing a very large list to select
108. ll be generated The first file will cover the dates 1 15 1 31 the second file will start on February 1 and cover a full month while the third file will start on March 1 and go through March 15 VERSION 6 5 90 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Advanced Data Export processes all requests by generating one or more XML files XML is the standard by which PA PSRS exchanges data with facilities Helpful Tip For a more detailed explanation on the Advanced Data Export feature see the PA PSRS Advanced Data Export Users Guide located under the Resources tab within PA PSRS VERSION 6 5 91 JUNE 2015 Chapter f Communications Report Follow up A member of the PA PSRS Program and or Department of Health DOH staff may contact you to follow up on individual reports submitted to the system For example e When a report may represent a new or emerging threat to patient safety e When program staff would like to request more detail than is contained in the report e To provide the facility with relevant feedback from PA PSRS or from other authoritative sources of patient safety information e When there is the possibility of immediate patient jeopardy In addition if a report contains individually identifying information you may receive a message from PA PSRS staff notifying you of this error When the Authority receives an anonymous report of a Serious E
109. ly allowable score allowed is B2 since any report of this type would be seen as the active recovery efforts by caregivers to prevent a safety event e Questions 11 and 12 ask you to identify the likelihood of the event s reoccurrence and the likely severity of the event should it reoccur These questions together form the basis of a severity assessment index a tool for prioritizing reports for special attention or analysis Help in answering these questions is available by clicking on Definitions These questions and the criteria for answering them are based on the Severity Assessment Code system developed by the Veteran s Administration s National Center for Patient Safety e Click Next Page when finished a Tuesday September 13 2005 PA Pennsylvania Patient Satety Time remaining 14 53 PSRS Reporting System Reset Timer Event Report S Describe The Event Please include all relevant information including details on how or why the event accured maximum 1000 characters TA Harm Score check ong 8 Ho Himi we Be An ewani occurred but it did nol reach thee individual near miss ar Hose call because of active recovery effcats Ds CM egtee s ii Likelihood Of Event Recurrence vx Definitions i Severity Of Efeci Resulting From Recurrence Of Evert v Definitions NextPagqe Top of Fage j Cancel Retum t Questions 1 4 5 8 Screen 5 Health IT Question 13 e Question 13 asks you whether Health IT caus
110. main Report Selection screen see below where you can select which analytical report you wish to create P Pennsylvania Potient Safety ETE MENS PSRS Reporting System Organization Training Facility Help Report Selection Criteria Summary ted Reports by Typ Report style Chant Tabular Fi oof 15 Ex Mont Hem core Lstnibubon Report uabenis Sion Type Serious Event E verni Deta Harm ite Orstnbuto Cate inciden Tor 1Ewvert ypes by pa fi Pp Hah Alert Medicehons and Steps In The Mechcaton Process Infrastructure Failure M ducmtn F nributing To Fu T F ot Fa P a ls Cial ia E 3 Other L tais rFupleated to False m nE di m m d Ent Kad i nb nar Generate Report To Main Page Additional Criteria The following reports are available to all hospitals summary of Submitted Reports by Type Harm Score Trends by Month Harm Score Distribution Event Detail by Harm Score Distribution of Subcategories Top 3 Event Types by Care Area High Alert Medications and Steps in the Medication Process Medications Contributing to Risk for Fall Details Related to Falls Distribution of Potential Contributing Factors Additional reports are available to hospitals enrolled in the falls reporting program see Chapter 8 Falls Reporting Program e Falls Rates Reports e Falls Risk and Strategy Process Measure e Falls Dashboard e Falls Tracking Groups Rates Reports e Falls Utilization Data Reports Simply select which report
111. n to promote the safe and effective use af equipment management Physical The physical environment is free of hazards This includes furnishings environment hardware ie g bars hooks rads lighting distractions The adequacy af the process for proactively conducting a risk assessment and taking actions based Upon evaluation of the impact of buildings grounds equipment occupants and internal physical systems on patients and public safety Security systems The processes to manage the environment of care including processes and and processes activities which will prevent patient staff and visitar accidents and injuries as wall as maintain an environment which is sensitive to patient needs for comfort social interaction positive distraction and selfcontrol Control of The processes in place that support safe medication use This includes medications formulary management storage control prescribing dispensing storage access administration and distribution of prepackaged medications obtained form outside sources Labeling of All medications dispensed to inpatients ar outpatients are appropriate and medications safely labeled using a standardized method Print Close 71 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE REPORT CODING Table 5 3 Eindhoven Root Cause Analysis Categories Question 19 Catego Code Latent errors Errors resulting from underlying system failures
112. na Reus Ihn Acker Aj qu aures VERSION 6 5 31 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Screen 6 Recommendations and Disposition Questions 14 15 e Question 14 allows you to describe any changes you are making in your facility or lessons learned to prevent this type of event from reoccurring These can include the development of new policies and procedures changes in operations or staffing patterns or even facility modifications NOTE DO NOT INCLUDE THE NAME OF ANY PATIENT OR HEALTHCARE WORKER IN YOUR DESCRIPTION e Question 15 asks you to identify the disposition of the event e Click Next Page when finished F 1 Tuesday September 13 2005 PA3 Pennsylvania Patient Sofety Time remaining EEEESN PSRS Reporting System oset Time Help Event Report Organization Training Facility 14 Recommendations For System Improvement Include any lessons learned and steps you are taking to prevent recurrence or a similar event in the future maximum 500 characters 15 Disposition Of Event check all that apply N L Refer to medical director a Refer to oversigh peer review committee C Report to JCAHO Maintain report for review and trending Refer to quality improvement monitoring committee Referto risk management safety committee Patent safety committee Medication event review committee C Medical staffs service committee Other specify
113. ng boards VERSION 6 5 5 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE INTRODUCTION Acknowledgements The PA Patient Safety Reporting System PA PSRS was developed and is maintained by ECRI Institute under contract to the Pennsylvania Patient Safety Authority ECRI Institute is a Pennsylvania based independent non profit health services research agency headquartered in Plymouth Meeting Montgomery County Its focus is healthcare technology healthcare risk and quality management and healthcare environmental management ECRI Institute is a Collaborating Center of the World Health Organization and is designated an Evidence based Practice Center EPC by the U S Agency for Healthcare Research and Quality AHRQ Hewlett Packard Company HP together with its subsidiaries provides products technologies software solutions and services to individual consumers and small and medium sized businesses SMBs as well as to the government health and education sectors worldwide HP was founded in 1939 and is headquartered in Palo Alto California with local offices in the Harrisburg area The Institute for Safe Medication Practices ISMP based in Horsham Montgomery County is providing analytical support and technical assistance to the PA PSRS program ISMP is a non profit organization that works closely with healthcare practitioners and institutions regulatory agencies professional organizati
114. ng data from the system Logging On VERSION 6 5 PA PSRS is accessed via a secure password protected website via the Internet You can access the system from any computer that meets the following specifications e Microsoft Internet Explorer 8 or later Compatibility Mode may need to be activated e Support for session cookies non persistent e Support for JavaScript e Local administrative privileges during installation of ActiveX controls required to generate graphical reports e Access to the internet e e Mail account e Adobe Acrobat Reader V8 0 You will be able to download Adobe Reader directly from the PA PSRS main screen 8 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE GETTING STARTED To reach the PA PSRS Home Page direct your browser to the following URL http www papsrs state pa us Patient Safety Authority EAS T l E HM T SAFETY amp TH eRIT Y a Patient Safety Authority Home Page Advisories Anonymous Report PSRS Pennsylvania Patient Safety Reporting System a Contact Us Mandatory Reporting System User ID O Click Here ta change your password Forgot your password BI Zucbcus Password Request Contact Change Form a Click Here To Login check here to enter Report For Assistance PA PSRS has been designed Help I get a 404 File Not Found Error for use with Turn on Compatibility Mode x
115. nin To be considered an imcident mu exent occumenca nr situgtiom must meet all of fre felicwing criteria involved the clinical cam of a pabon in a medical facility Could have injured the paseni Ded nol cause an unanboipated injury requiring additional healthcare zeneices to the passent Infrastructure Failure An undesirable or unintended char rae casar s aD invohing the infrastructure of a medical Lacility or discontinuation or significant decis acetic coll seriously compromise patient safety Remember To be considered an inirastrecture failure P ell pli cria under Columo A ac all e Pa GEATA unde Colum A or Gales B m a Anusasrable Qr gb unantcipated event GCCUITPACH oF situation B ere eee gi unm un iujficant demupbas of a Gould seroushy compromise ooo NR paleni safely patent say Other CMS requires hospitals to report to DOH any death in restraints or ee vn wapa qe rigueur rig ra roa a virium prpope Jeaths h the RJ Fowdback ta PSA bakma pania vi s reporting sysiem i protedad uer applostia State ard Fadvi ips aed shall rhy be ned or dadioned ia oppaana wah Goes tama art VERSION 6 5 24 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Helpful Tip To move back and forth between screens do not use your browser s Back and Forward buttons Use the hyperlinks to move between sections of the reporting form If you accidentally use your br
116. nistration on the Navigation Bar 2 Click Add New User in the pop up menu 3 Enter the information requested on the screen below and select Yes to the question Can this user enter and amend PA PSRS reports 4 Click Save when done PA 3 Pennsylvania Patient Safety PSRS Reporting System Monday October 3 2005 Help fals Program Resources f toor O Add User User ID Required Initial Password password First Name MI Required Last Name Required Title Address Line 3 1 Required Address Line 2 City State Zip Required P Phone Required Ext Fax Email Address Required Active In PA PSRS you can create two types of users e Those who can enter amend and read reports e Those who can only read reports Can this user enter and amend PA PSRS reports O es Ono If the PSO wishes to authorize other individuals only to view and analyze reports on his or her behalf you may add read only users by following these steps 1 Click User Administration on the Navigation Bar 2 Click Add New User in the pop up menu 3 Enter the information requested on the screen below and select No to the question Can this user enter and amend PA PSRS reports 4 Click Save when done An FSM has the ability to reset user passwords when needed This can be done when editing a user profile
117. nt Assessment after event Review of record or chart 3 Gender Of Affected Patent check one L Mate L Female L Not applicable check for events involving zero or multiple patients 4 Age Of Affected Patent Equal or greater than 2 years years Under 2 years months Under one month days Not applicable check for events irreoMng zero or multiple patents Next Page Top of Page Cancel VERSION 6 5 51 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Screen 3 Questions 5 through 8 e Answer each question by selecting the appropriate check boxes entering the information requested into the dialog boxes or using the pull down menus For questions 6 7a and 7b click on the calendar icon to get a pop up calendar that can help you answer these questions e Note that question 6 permits the response Not Applicable and that Question 7 includes sub questions 7a date the event was confirmed and 7b explanation for any reports submitted more than 24 hours after confirmation e Question 8 asks you to identify the event type using the taxonomy for Other events The only event type available is Z Restraints and seclusion To choose the event sub type position your cursor over the words Point here This will bring up a menu of possible selections e Click Next Page when finished to proceed to the next screen PA g Pennsylvania Patient Safety Friday Februar
118. nt to prevent recurrence Providing specific recommendations for prevention or mitigation will help PA PSRS to develop useful information for other Pennsylvania healthcare organizations Please include the following elements in your description s Critical elements Example Drug Administered to Wrong Patient Who GENERIC provider roles Nurses and nurse s aides What action plan Will verify patient identity Where types of sites at all locations in the facility When in context before each medication administration How method by comparing the medication administration order with the patient s arm band Why lesson learned Multiple independent system safeguards must be in place from the physician s order to the pharmacy to the bedside Include only generic descriptors of persons and places Never include identifying information VERSION 6 5 33 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 Screen 7 Follow up Questions Questions 16 22 In many cases you may not be able to answer with certainty the Follow up Questions at the time you are completing an initial report When this is the case provide answers that best represent your current understanding of the event You can amend the report or provide additional information for up to 90 days after submitting your initial report Later in this chapter we provide instructi
119. nu with only one selection Retrieve Event Report By Report ID To perform this function simply click on your selection This manual addresses the specifics of performing these tasks in later chapters For now familiarize yourself with the Navigation Bar and the available selections Main Page Event Report Create New Event Report Not seen by Read only User Amend Event Report Not seen by Read only User Retrieve Event Report By Report ID Utilization Data Enter New Utilization Data Not seen by Read only User Edit Utilization Data Not seen by Read only User View Print VERSION 6 5 10 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE GETTING STARTED View Completed Report Amendments to Report Print Completed Report Amendments to Report Blank Forms Event Report Serious Event Incident Infrastructure Failure Event Details Medication Error Adverse Drug Reaction Equipment Supplies Fall Error Related to Procedure Treatment Test Skin Integrity Patient Self Harm Event Type List Anonymous Form Definitions Download Adobe Acrobat Reader Analytical Data Tools Search Submitted Event Reports Event Report Data Analysis Data Export Standard Data Export Advanced Data Export Downloadable Data Files Resources Training Manual Training Slides Program Memorandum Advanced Data Export Users Guide Logoff If you logged in as the Facility System Manager your Navigation Bar will appe
120. o D dd DE 12 TOES SV ORI COM ON uer SR Ep EL E DUM E P ED E D MM CN IZ Password Valdano Reate usus oe d t Hed c Hm Edu tO dU adu nie ts hei beck c CA do EUER Re dac eS T2 FACIEITY MANAGEMEN Dora eeeetu un etus eut a Yu e nca eta Cup gu eve iot Cea ao ao ac der ne eue tao eee esae een uota cerei Oc E FEY uev Eoo E eee ea ee Deua pee uua ua 14 ROLE OF THE FACIEITY SYSTEM MANAGER x 4see ode toa e exteeslagatistiac tutus dee he sa etus e tese uude tu ou a one cabe ae a oreet ai 14 USER ZXDMINISTRATION s 3e eese 5 ete a a AA C ET ht ta a UR CI MD ae Ses 14 CAREAAREA ADMINISTRATION 25526 retocisece eese eae tet le ae audet ce to Bot et Ba etus tod el a E a 16 Adame COV CTAT COS RR 16 PUT ENA LAV CS carta aaa asad H 17 PONCHO OPPETO etasumcadudest sud event ausis ous tae es Scand dasvensa eas tocar dere es een imet tuv cupide pA uet s tmu iuS qute eats 17 COO NV CA ET M 17 CARE AREA GROUP ADMINIS ERATION 9 3 aibetzctaetet ved evicdeet osten lose Dont Ced us teste busto ve lose e et me dou o ew doe ve Gd eu E ERR 18 FAL S REPORTING PROGRAM BENROLEMENT actesioiciovetetuetatte tes eioed nsi qe tet tutes aerei etc dee aae dnte bee eaaet aue teu las t to eu o De oes 19 EVENIREPORTSS2 heec rcu UEM iL RE LL d M LM I E EE 20 REPORTABLE WIENS ce C A mmm 20 Wharis a Tepo aDC CV CIE 7 2n oss a esistere E ibe t ins chiedi ea ne
121. o the best of your knowledge Do vau wish to submit this report at this time When you do click OK you will see the screen shown below which confirms that your report has been submitted The report will be assigned a unique Report Number which you can record You will also have the option to print out a summary of the report you just submitted or immediately begin to enter a new event report Managing Submitted Reports You can manage your reports from the main page the first page you see when you log on see below VERSION 6 5 58 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS PA 2 Pennsylvania Patient Safety M PSRS Reporting System Organization Training Facili Help KCSCHIBC T TUIK TUR ETT TAE TTE CHIC 8E n Date 06 16 2005 to 09 14 2005 new date range Showing 1 20 of 176 Total Records Selected Report ID Report ID TBD Report Type CareArea Event Type rolh ae TN Event Date amp Time a TV T T T4 T4 TV T T T 49530 Infrastructure Test Care A rea11 X Other Infrastructure Failure A 89 09 12 2005 22 22 9 13 2005 15 04H 49520 Infrastructure Test Care Area11 X R Emergency Services Response A 89 09 12 2005 11 11 9 13 2005 15 02H 49511 Serious Test Care Area 11 A Medication error E 89 09 1 2 2005 22 22 9 13 2005 14 47H 49469 Incident Test Care Area 12 E Error related to Procedure C 89 09 1 3 2005 Unknown 9 13 20
122. ols falls Pages algorithm as px under Educational tools The first question to be revised is Question H Fall precaution protocol in place This question has 8 identifiable falls prevention strategies If there are no falls prevention strategies indicated or it is unknown chose one of these options and then move to the next question When yes is chosen select at least one of the 8 fall prevention strategies The last prevention strategy listed is other and is a free text field Enter any fall prevention strategy that is not currently listed The eight fall prevention strategies include Patient risk identifiers e g wrist bands visual cues on the walls or charts Patient and family education Hourly or more frequent comfort and toileting rounds Nurse call system Alarms present bed exit or chair Appropriate footwear clothing Equipment used bedrails up high low beds fall mats Other specific text field limit 50 characters H Fall Precaution Protocol in Place Yes C No C Unknown Type check all that apply E Patient risk identifiers Patient and family education Hourly or more frequent comfort and toileting rounds Nurse call system Alarms present bed exit or chair Appropriate footwear clothing Equipment used bedrails up high low beds fall mats Other specify Question K is also revised The question originally read Drug induced The question now asks Was fall drug induced K Wa
123. ons and the pharmaceutical industry to provide education about adverse drug events and their prevention The Institute provides an independent review of medication errors that have been voluntarily submitted by practitioners to a national Medication Errors Reporting Program MERP operated by the United States Pharmacopoeia USP in the USA The PA PSRS software program was developed in part based on Patient Safety Net a proprietary patient safety reporting application developed and maintained by the University HealthSystem Consortium UHC UHC based in Chicago Illinois is a non profit alliance of the clinical enterprises of 87 academic health centers Diversified Data Systems DDS based in Mechanicsburg PA provided assistance in developing the PA PSRS training program and this manual The Authority and ECRI Institute also wish to thank the Pennsylvania healthcare organizations who participated in the initial rollout of and subsequent enhancements to the PA PSRS program Their feedback and suggestions have helped to improve the usefulness of the system and their ideas will continue to influence future enhancements We appreciate their leadership and commitment to patient safety VERSION 6 5 6 JUNE 2015 Chapter 2 Getting Started Key system functions and startup Key System Functions The system is designed around the following key functions 1 System administration 2 Submitting reports of Serious Events Inciden
124. ons on how to amend an existing report You may revise your responses to these questions after additional investigation ranging from simply discussing the event with the individual who reported it through your facility s internal reporting system all the way up to a formal root cause analysis or other investigative technique PA PSRS allows you to record and analyze the results of your own investigations g oe Tuesday September 13 2005 P Pennsylvania Patient Safety Time remaining EEE PSRS Reporting System Reset Timer Help Event Report Organization Training Facility 16 Potential Contributing Factors check all thal ipii be a Teaan Facto s 1 Based on Harm Store selected no response is needed CI Communication problem betwren providers C Change of amp eerdce same care area CI Cross coverage situation O Shit change Unplanned workload increase O Holiday Hone Ta be determined b Work Errai operit Based on Harm Score selected no response is needed n Distractionsmnberrupiiong Limited access to patient information Poor lighting C High moise hevel Equipment malfunction inadequate equipment availability C None C To be determined Task Factors Based on Harm Score selec led no response is needed COl Training issues LI Emergency smuabon inexperienced staff inadequate residen supervision Cardiacimespiratory amest situation a Order eniry zystem pra
125. or example your facility may decide to institute a policy where all reports of a certain severity score or higher should receive a certain level of investigation such as a root cause analysis or failure mode and effects analysis Harm Score VERSION 6 5 The harm score is requested in Question 10 The harm score measures a the extent to which the event reached the patient and b the degree of harm the event caused to the patient see Table 5 1 There are 10 categories in the harm score taxonomy labeled from A through Events closer to category A resulted in less harm to the patient than events closer to category I Table 5 1 Harm Score Taxonomy Unsafe Conditions Circumstances that could cause adverse events e g look alike medications confusing equipment etc Event No Harm B1 An event occurred but it did not reach the individual near miss or close call because of chance alone B2 An event occurred but it did not reach the individual near miss or close call because of active recovery efforts by caregivers An event occurred that reached the individual but did not cause harm and did not require increased monitoring an error of omission such as a missed medication dose does reach the individual An event occurred that required monitoring to confirm that it resulted in no harm and or required intervention to prevent harm EvntHamm 0000000000000 Harm pM gps ML event occurred that contrib
126. ore Help Selection Criteria Report Style v Serious Event v Incident v Infrastructure Failure Report Submission Type Event Date Current Year Gender All Age AII Care Area All Select New Criteria Choose New Report Return to Main Page Regenerate Report File Edit Tools View Gallery Facility Event Detail by Harm Score Harm Score Definitions JUNE 2015 78 VERSION 6 5 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS PA PSRS Statewide Aggregate Event Detail by Harm Score Unsafe Conditions Harm Score A No Harm Harm Score B1 B2 C D 5 5 274 7h 17 14 15 E 5 33 2 p 8 5 6 5 5 5 17 19 Harm Harm Score E F G H Death Harm Score 4 4 17 8 21 25 8 8 100 amp Medication error Wl B Adverse Drug Reaction not a medication error C Equipment Supplies Devices D Fall B E Error related to Procedure Treatment Test e F Complication of Procedure Treatment Test Bl G Transfusion H Skin Integrity Other Miscellaneous B n Emergency Services Response S Physical Plant Utilities Service Disruption T Administration Management U Medication Safety X Criminal Potentially Criminal or Illegal Activity X Other Infrastructure Failure Harm Score Definitions Distribution of Subcategories This report presents either as a series of pie charts or tables
127. ore reaching the last screen or before clicking on Submit Report this will also cancel your report submission VERSION 6 5 25 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Screen 3 Questions 5 through 8 e Answer each question by selecting the appropriate check boxes entering the information requested into the dialog boxes or using the pull down menus For questions 6 and 7 click on the calendar icon to get a pop up calendar that can help you answer these questions e Question 6 includes sub question 6a Patient Status with three patient status choices Inpatient Outpatient and Unknown see explanation below e Question 7 includes sub questions 7a date the event was confirmed and 7b explanation for any reports submitted more than 24 hours after confirmation e Question 8 asks you to identify the Event Type See Appendix B for more detailed information about the Event Type list To select the Event Type first make a selection from thee first drop down box under the words Event Type followed by a selection from the second drop down box then a selection from the third drop down box if it is enabled When no selection is needed from the third drop down box it will be disabled e Click Next Page when finished to proceed to the next screen PA y Pennsylvania Patient Safety Friday February 24 2012 PSRS Reporting System Time remaining Event Report amp
128. ort investigating the cause of an unexpected death whereas a minor bruise that seems like an isolated occurrence may not warrant as much attention Two systems are currently in wide use around the country for classifying the severity of a patient safety report the harm score taxonomy developed by the National Coordinating Council for Medication Error Reporting and Prevention NCC MERP and the severity assessment code system developed by the Veterans Administration VA National Center for Patient Safety PA PSRS has adapted both of these systems to meet the requirements of MCare and incorporated them into the PA PSRS software application After your facility has used PA PSRS for a while and developed a sizeable database you will be able to produce data tables charts and graphs that show the number or percentage of events by VERSION 6 5 65 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE REPORT CODING severity For example one way to demonstrate progress toward your goal of improving patient safety might be to show that during a period when the overall number of reports is increasing the overall severity of those reports is decreasing This could suggest that more potential events are being caught in time to either prevent or minimize harm to patients Report severity can also be used to prioritize reports within your institution for follow up by or discussion among your Patient Safety Committee F
129. otor physiologic ar intellectual nat related to the natural course ofthe patient s illness ar underlying condition d e acts of commission or omissioni Suicide inpatient ar outpatient Hemolytic transfusion reaction eurgeryPracedure on the wrong patient ar wrong body part Infant abduction ar infant discharge ta the wrong family Death ar major permanent lass of function thatis a direct result af injuries sustained in a fall ar associated with an Unauthorized departure from an around the clock treatment setting ar the result af an assault or other crime Major Patients with actual or potential Permanentlessening of bodily functioning sensory motor physiologic or intellectual not related to the natural course of the patient s illness ar underlying conditions i e acts of commission ar omissioni Disfiguremaent Surgical intervention required Increased length of stay for 3 ar mare days Increased level af care for 3 ar mare days Moderate Patients with actual or potential Increased length of stay far up to three days or increased level af care for up to three days Minor Ma increased length of stay ar increased evel af care Print Close Note Adopted from the eterns Health Administration oa 7030 T VERSION 6 5 68 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE REPORT CODING Event Type VERSION 6 5 The Event Type taxonomy helps you to classify each report so
130. oup aggregate falls rate i e the comparison falls rate will be displayed as a single rate averaged over the selected time period is shown below Facility Falls Rates vs Peer Group Facility Falls Rates June 2012 to August 2012 Peer Group Acute Care Hospitals over 300 beds Falls Per 1 000 Patient Days Jun Jul Aug M 3012 3 mete Facility Falls Rate Peer Group Aggregate Falls Rate Feer Group Aggregate Falls Peer Group Aggregate Falls Rate Upper ConfidenceLevel Rate Lower Confidence Level M missing data A maximum of 21 facilities are included in the comparison group calculation Each time penod is calculated separately and it s possible that each time period has a different number of facilities that are included in the companson group calculation The comparison group calculation must have at least 5 facilities to work Unit level enrollment Hospitals enrolled at the unit level will have two different falls rates report selections Falls Rates Report and Falls Rates Report Inpatient vs Outpatient Care Areas Unit level enrolled hospitals will have access to all the configurable options listed above There are three main types of Falls Rates Reports available based on the utilization data Patient Days provide falls rates for inpatient care areas Patient Encounters provide falls rates for outpatient care areas e g ED radiology physical therapy Adjust
131. ous Events and Incidents MCare also requires facilities to report Serious Events and Infrastructure Failures to the Department of Health DOH The Authority has developed the Pennsylvania Patient Safety Reporting System PA PSRS to e Collect Serious Event Incident and Infrastructure Failure reports from MCare covered facilities e Facilitate internal analysis and reporting of patient safety related data within each facility e Facilitate aggregate data analysis across facilities and development of preventive recommendations to improve patient safety e Serve as an educational resource and quality improvement tool for healthcare provider organizations and their Patient Safety Committees Reports are submitted to the Authority and the DOH as appropriate using a single interface Note that e Reports of Incidents are submitted only to the Authority They are not accessible to the DOH e Reports of Serious Events are submitted BOTH to the Authority and to the DOH for their respective statutory requirements 1 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE INTRODUCTION Reports of Infrastructure Failures are submitted only to the DOH They are not accessible to the Authority The Manual is organized into the following chapters and appendices VERSION 6 5 Chapter 1 Introduction explains the purpose of the Training Manual and Users Guide presents an annotated outline of the manual
132. outcome of the event In Question 9 you are asked to describe the event NOTE DO NOT INCLUDE THE NAME OF ANY PATIENT OR HEALTHCARE WORKER IN YOUR DESCRIPTION e Question 10 asks you to select a harm score which measures a the extent to which the event reached the patient and b the degree of harm the event caused to the patient This harm score is adapted from a system developed by the National Coordinating Council for Medication Error Reporting and Prevention NCC MERP See Chapter 5 for more detailed discussion of the harm score and how to interpret it e Questions 11 and 12 ask you to identify the likelihood of the event s reoccurrence and the likely severity of the event should it reoccur These questions together form the basis of a severity assessment index a tool for prioritizing reports for special attention or analysis Help in answering these questions is available by clicking on Definitions These questions and the criteria for answering them are based on the Severity Assessment Code system developed by the Veteran s Administration s National Center for Patient Safety e Click Next Page when finished A g r a Tuesday September 13 2005 P Pennsylva nia Patient safety Time remaining 14 53 PSRS Reporting System Reset Timer Help Event Report 9 Describe The Event Please include all relevant information including details on how or wey Ene erent occured maximum 1000 characters t Harm Score check one
133. owser s buttons to navigate you will need to hit the refresh button to continue Screen 2 Questions 1 through 4 e Answer each question by selecting the appropriate check boxes or entering the information requested into the dialog boxes e Click Next Page when finished to proceed to the next screen e Note the Time remaining box that appears in the upper right hand corner of the screen You have 15 minutes to fill out the page the timer resets for each page If you allow the system to time out the program will automatically close the session and your report will be lost Click on Reset Timer at any time to reset the timer to 15 minutes P Pennsylvania Patient Safety Nednesday January 21 2015 s Time remaining PSRS Reporting System mum Timer Help Event Report 1 Report Submission Type Choose only one Senous Event Incident Infrastructure Failure Other 2 How Was This Event Discoverned check ail that appi Witnessed Imoved Report by patent Report by family or visitors Report by staff member Report by resident fellow or student x xc s Review of record or chart 3 Gender Of Affected Pabent check one Mae Fermo 4 Age Of A tected Patent Equal or greater than 2 years years Under 2 years months Under one month cays Next Page Top of Page Cancel Helpful Tip Note that you can abort a report submission by hitting Cancel Also if you close your browser at any point bef
134. per 1 000 patient days Falls and Falls with harm per 1 000 patient encounters Falls and Falls with harm per 1 000 adjusted patient days e Falls Risk and Strategy Process Measure e Falls Dashboard VERSION 6 5 106 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Periodic Falls Rate Facility Level Patient Days Falls Rates Quartiles Falls Risk Assessment Falls Details Falls Prevention Strategies in Place e Falls Tracking Groups Rates Reports Inpatient falls tracking groups Outpatient falls tracking groups e Falls Utilization Data Reports Monthly compliance summary Unit level compliance details To access available reports select Analytical Data Tools from the Navigation Bar then select Event Report Data Analysis from the drop down menu Main Page Event Report Utilization Data View Print Blank Forms Analytical Data Tools Event Report Data Analysis Event Report Data Analysis Nursing Homes View Statistical Reports This will take you to the main Report Selection screen see below where you can select which analytical report you wish to create The report screen where the PA PSRS user can select a report will be determined by enrollment status e Facility level enrolled hospitals will have access to the falls rates facility report falls risk and strategy process measures report falls dashboard and falls utilization data report Report Selec
135. randum No 2013 02 for more details about creating and changing passwords VERSION 6 5 13 JUNE 2015 Chapter 3 Facility Management How to set up and maintain the system for your organization Role of the Facility System Manager The Facility System Manager is responsible for these functions in the system e Assigning user IDs and passwords to other users in the facility or conversely removing user IDs or passwords if for example a person is no longer employed by your facility e Establishing care areas and care area groups that will help define the location of events within the facility e Enrolling in the Falls Reporting Program available to HOSPITALS only The Facility System Manager and PA PSRS User both perform different functions however it is possible for an individual to maintain both roles under separate log in id s Recognizing that some organizations prefer to have different individuals handle these functions we have defined a unique role for the Facility System Manager to offer this option There are separate User ID and password combinations for the Facility System Manager and a PA PSRS User Even if the same individual serves both roles they will need to use the Facility System Manager login to perform administrative functions and the PA PSRS User login to work with event reports and perform data analyses We recommend that both PA PSRS Users and the Facility System Manager review the material in
136. rase the clinical care of the patient which is a part of the definition of a Serious Event and an Incident Does PA PSRS oollect information on events that do or could compromise the safety of healthcare facility staff and or visitors PA PSRS only collects information related to the safety of patients While healthcare worker and visitor safety are certainly important they are beyond the scope of MCare and PA PSRS 21 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS VERSION 6 5 Part of the definition of Serious Event relies on whether the event compromised patient safety How do we know whether patient safety has been compromised This is another area where a facility must rely on the best judgment of its Patient Safety Officer members of the Patient Safety Committee and risk management staff However some events and their consequences are sufficiently minor that they may not rise to the level of Serious Event Incident Infrastructure Failure or Other event and may not be necessary to report under MCare at all Part of the definitions of Serious Events and Incidents relies on whether a patient sustains an unanticipated injury When is an injury unanticipated What about adverse events that are not the results of a medical error You may sometimes question whether you should report adverse events that are not the result of a medical error and or are seen as routine comp
137. rch screen while logged in as a PS PSRS User or Read only PA PSRS User select Analytical Data Tools from the main screen menu bar then select Search Submitted Event Reports This will take you to the following search interface PA Pennsylvania Patient Safety PSRS Reporting system Wednesday September 14 2005 Help Selection Criteria Select a Facility fA v 1 Report Submission Type Required Serious Event Incident 2 Date Required SEventDate OAdmitDate Submit Date From ES ro o9 42005 ES 3 Event Time Optional From All v To Al v And Or C Unknown Time A CONAN ON HUN e COUR Man Omon Otve Owed Oth Orr Osat Osun 5 Gender Optional All Female Male 6 Age Optional v Or Years Months Days From To 7 Care Area Optional eee All To specify a care area you must select a facility 8 Harm Score Optional All Definitions Da Om Oe Oc Oo Oe OF Osc OM DOi 9 Event Type Optional All Add Change Event Type Criteria Clear Criteria Hj Generate Report Go To Main Page VERSION 6 5 87 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS From this page you may specify the criteria for the reports you wish to view These criteria include Report type Serious Event Incident or Infrastructure Failure Date either by date of event or date of admission Event time of day and day of the week Age and gend
138. rd error in these categories is simply meant to distinguish these event types from those that immediately follow them For example under Medication Error administering a dose of medication to the wrong patient is clearly an error 69 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE REPORT CODING Whereas an Adverse Drug Reaction Category B while of interest from a patient safety perspective is not necessarily the result of an error Another important point to note you should not assume that simply because an event type code exists in PA PSRS that this type of event is always required to be reported under MCare Root Cause Analysis VERSION 6 5 Questions 18 and 19 in the PA PSRS reporting forms provide tools that can be used for conducting a root cause analysis RCA In Question 18 the system prompts you to select up to three root causes from a defined list based on the Joint Commission guidance document Minimum Scope of Root Cause Analysis for Specific Types of Sentinel Events The full list of codes for Question 18 is shown in Figure 5 2 A second method of coding reports for the results of an RCA is based on the Eindhoven Classification Scheme Medical Version originally developed by Van der Schaaf et al fand popularized by the Medical Event Reporting System for Transfusion Medicine MERS TM developed in the mid 1990s Though the MERS TM program remain
139. rmation PHI that is individually identifiable health related information The PA PSRS program was specifically designed to prevent the collection of PHI We have taken all reasonable steps to ensure that PA PSRS does not request any information that can be used to match an event report in the database with a particular patient such as a name date of birth or medical record number Further the system does not request information that could be used to identify individual healthcare workers who may be involved in a reportable event such as names employee numbers or Social Security numbers Although there are no fields in the database that request PHI it is still possible that system users could enter PHI either intentionally or unintentionally in free text fields We strongly encourage facilities to pay special attention to their HIPAA obligations PA PSRS has established a principle that PSRS staff members may not modify or delete data submitted by a facility Therefore each PSO must be responsible for the integrity of their data See also System Confidentiality above Impact of PA PSRS on Reporting to Other Organizations PA PSRS supports reporting to both the Patient Safety Authority and the Department of Health DOH Reporting through PA PSRS does not relieve a healthcare facility of any obligations it may have to report to other federal state or local government agencies independent accrediting organizations or licensi
140. room rehabilitation services radiology This definition includes emergency room patients prior to formal admission and emergency room observational patients This EXCLUDES any patient who is formally admitted while in the emergency room and is being held while waiting for a room It also includes patients who receive care in an ambulatory surgical facility birthing center and abortion facility Unknown Patients designated as unknown are assumed to be either inpatient or outpatient based on the reported location where the event occurred including falls for the purpose of calculating falls rates All reports from Ambulatory Surgical Facilities ASFs Birthing Centers BCs and Abortion Facilities ABFs will have this question auto filled to outpatient without the opportunity to change this designation This field will be disabled but visible for ASFs BCs and ABFs 104 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Fall Event Details When entering event reports for falls the Fall Event Details screen has revisions to two existing questions and three new questions Each question has the same three responses yes no and unknown A falls event decision tree was developed to provide a systematic approach to evaluate the circumstances surrounding falls and to standardize falls reporting and is located at http patientsafetyauthority org EducationalTools PatientSafetyTo
141. s the assailant Physical Assessment used to determine care based an the patient s physiological assessment psychosocial needs and the setting in which the care is provided Includes process T search far contraband Patient Process used to identify patients and assure that the right test treatment identification medication is given to the right patient process Patient Process used to monitor the patient based Upon the assessment and observation reassessment of a patient procedures Care planning Process of defining how care will be provided based on an process assessmentreassessment of the patient This includes monitoring modifying ar completing care based on assessments reassessments and coordinating follow up Staffing levels The number af staff staff s qualifications and competencies provided based on the volume and acuity of patients Orientation amp The organizations overall plan to orient and train staff based on job training of staff requirements The individualized plan forthe involved employee based on the employee s experience education and abilities Modifications made to the plan based on the employee s performance Competency Ongoing periodic evaluation of staff member physician s continuing assessment abilities to perform t their duties This includes data on qualifications such credentialing as license and training ar experience and data an actual performance that is collected and assessed initially and an
142. s could have had multiple falls details indicated The table of Falls Prevention Strategies in Place shown below identifies the top three falls event types stratified by prevention strategies that were in place for patients who fell for the time period selected The total number of patients represents only those patients with a prevention strategy in place Falls Prevention Strategies in Place Patient Hourly or Appropriate Equipment Used Top 3 Falls Event T i i e Id Luo A and Family gr 9 Footwear and Present Bed bed de ex Mdh Education Talet Hid Clothing or Chair j Found on floor Individual patients could have had multiple preventionstrategies in place Patienttotal represents all patients for each falls event type that hada prevention strategy in place Patients without a preventionstrategy indicated were excluded VERSION 6 5 119 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Falls Tracking Groups Rates Reports Facilities enrolled at the unit level are able to calculate falls rates for the following individual Falls Tracking Groups Inpatient Falls Tracking Groups Critical Care General Medical Surgical Inpatient Rehabilitation Intermediate Care Pediatrics Specialty Units Outpatient Falls Tracking Groups Emergency Departments Outpatient Clinics Radiology Services Rehabilitation Services A trend line falls tracking group falls ra
143. s fall drug induced Yes Mo Unknown VERSION 6 5 105 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM The three new questions are Question P Does patient have history of visual impairment this includes patients who wear corrective lenses Question Q Does patient have history of hearing impairment Question R Does patient have prior history of falls in the past 12 months P Does patient have recent history of visual impairment Yes NO Unknown Q Does patient have recent history of hearing impairment Yes NO Unknown R Does patient have prior history of falls in the past 12 months Yes No Unknown After completing the Fall Event Details return to questions 9 through 21 of the Event Report Including Event Outcome Recommendations and Disposition and Follow up Questions as explained in Chapter 4 Event Reports pages 24 30 Once all the questions have been answered click Submit Report and follow the instructions on the screen These final steps are explained in Chapter 4 Event Reports pages 30 32 Falls Analytic Reports Hospitals enrolled in the Falls Reporting Program have access to analytic reports in addition to the existing falls reports which remain available to all hospitals as described in Chapter 6 Data Analysis The Falls Reporting Program analytic reports include e Falls Rates Reports Falls and Falls with harm
144. s focused on errors related to blood transfusion the Eindhoven model is widely applicable throughout medicine for coding and classifying the root causes of errors and near misses that are the final output of a formal root cause analysis Figure 5 3 presents the list of Eindhoven model codes and their definitions 2 JCAHO 2002 Minimum Scope of Root Cause Analysis for Specific Types of Sentinel Events Available online at http Awww jcaho org accreditedt organizations ambulatory care sentinel events forms and tools root cause analysis matr ix htm Accessed 10 28 03 3 Battles JB Kaplan HS Van der Schaaf TW Shea CE The attributes of medical event reporting systems experience with a prototype medical event reporting system for transfusion medicine Arch Pathol Lab Med 1998 Mar 122 3 231 8 Kaplan HS Battles JB Van der Schaaf TW Shea CE Mercer SQ Identification and classification of the causes of events in transfusion medicine Transfusion 1998 Nov Dec 38 11 12 1071 81 70 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE VERSION 6 5 REPORT CODING Figure 5 2 JCAHO Root Cause Analysis Categories Question 18 Definitions Term Definition Behavioral Assessment forthe special needs of patients receiving treatment for assessment emotional or behavioral disorders Includes assessment of patient s risk to process self rand ta others in cases of assault rape ar homicide where a patient i
145. s to look at all event types but by choosing specific event types e g medication errors complications of a procedure treatment test etc you can study whether different event types are characterized by different contributing factors From the main report selection page you can select report type Serious Event Incident or Infrastructure Failure By selecting Additional Criteria you can modify the report by event date event type gender or age of affected patients or care areas PA Pennsylvania Patient Safety PSRS Distribution of Potential Contributing Factors Wednesday September 14 2005 Reportin system Organization Training Facili Help Selection Criteria Report Style Chart Report Submission Type Serious Event Incident Infrastructure Failure Event Date Current Year N Gender All Age All Care Area All Event Type ALL v Regenerate Report Select New Criteria Choose New Report Return to Main Page File Edit Tools View Gallery Facility Potential Contributing Factors Summary Report 6 6 15 17 15 12 17 19 a Team Factors 15 Bl ob Work Environment 15 c Task Factors 17 d Staff Factors 19 ll e Patient Characteristics 12 E f Organization Management 17 BB a Other 6 Select New Criteria Choose New Report Return to Main Page 85 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS
146. ssccseessceseesscssecssesseeseesecsesaecsseeseeeseaeeeeenees 125 MEDICATION ERROR EVENT DETAILS QUESTIONS 525i Stis sue TUE ET natas Und ia aa Dk Qe UE uS eei S EUN N STE Pep NUS CUI SE Do ainiai asais 133 ADVERSE DRUG REACTION EVENT DETAILS QUESTIONS eese nennen enne eene nennen eerte n ense teres e enses senten inns 138 jg E ey INE BOSE Ms CO ING EO mem 140 EQUIPMENT SUPPLIES DEVICES EVENT DETAILS QUESTIONS eese nennen nennen enne ern senten seen senes e nnns 142 ERROR RELATED TO PROCEDURE TEST TREATMENT EVENT DETAILS QUESTIONS eee nnne nnns 143 VERSION 6 5 II JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE TABLE OF CONTENTS SKINJINTEGRITY EVENT DETAILS QUESTIONS 5tticue tones tto ie aote te uad beu dde lot dede eo uid 143 EVENT DETAIL QUESTIONS INFRASTRUCTURE FAILURE sccsscssssssesscsssesscssecssceseesscsseesscsseessesseeseeseeseeaeeaceeesssseaeenseeseas 144 CAPACITY EVENT DETAILS QUES TIONS dete mcdio tvi colat T ee atte teste dits 148 EVENT DBETAIEOOUESTIONSAOTHERJBVENT 3 os sched oh talc Sah sles arte aat dat at uot o Ld ts 149 EVENT TYPE TAA ONOM Y opii ei ii i neue an avv vise t e e rel n ere m eR A I Ul ii a Er edv a E o du NE E IMS 154 SERIOUS EVENTS NOIDEN T acetate cscaeu sens cer asa E E eost MuR UEM DAN Du ste MdL A deu 154 Infrastrucidire baller i252 tet eto tained torto tat Dun ULM M SML RU LIN A E ELMAR hat tect 160 Bn
147. ssment table shown below identifies information about completed risk assessments identification of patients at risk for falls prevention strategies in place and prior history of falls The column responses reflect answers provided in the PA PSRS falls event detail questionnaire form which contains three responses Yes No and Unknown The No Response column indicates the number of patient event reports that have no response i e the data field is blank Falls Risk Assessment Completed Patient Identified at Risk of Fall Falls Precaution s in Place Prior History of Falls in the past 12 months The Falls Details table shown below identifies the top three falls event types stratified by patient characteristics of patients who fell for the time period selected The total number of patients in this chart reflects the top three fall event types as reported in PA PSRS If the total number of patients does not add up to the total number of falls identified at the top of the falls dashboard it means that there were four or more fall event types Falls Details Altered Requires Visual or mental assistance hearing from chair impairment Dizziness Altered Total elimination Patients Other Unknown specify Ambulating Thenumber of falls details represents Yes responses foreach patientcharacteristic Mo Unknown and blank responses were excluded Patienttotal includes all patient falls for that event type Patient
148. t Days Subtotal Patient Days from Other Unit Total Facility Level Patient Days Outpatient Care Area Occupational Therapy Outpatient Clinic Physical Therapy Radiology Total Patient Encounters Facility level Utilization Data Entry January 2012 Care Area Type Med Surg Pediatric Unit Surgical Unit caiculeted at cfTe wrsco Defueen Total F cility Levei Patent Deya and Lind Levei Patent Daya Subiot Care Area Type Rehab Occ Therapy O P Pediatric Clinic Rehab Phys Therapy Imaging Combined Services selected units above FALLS REPORTING PROGRAM Definitions Help 1H Patient Encounters When the Utilization Data menu option is selected a screen titled Enter Facility level Utilization Data for Month Year will be displayed Enter Facility Level Utilization Data for January 2012 Facility Level Data Total Facility Level Patient Days VERSION 6 5 Patient Days Pnnt t 101 Help Hesel JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM The facility level utilization data entry screen has one row titled Total Facility level Patient Days Enter your facility s total monthly patient days in the box at the end of this row Once the utilization data has been entered click the Save button at the bottom of the screen Print a hard copy of the utilization data page by clicking the Print button
149. ters Erect Type Larval Select Event Type Sob Lauagceg Lava Z T Chus iai Ta alee Ll 3 tre pert Hont Page Top of Page Cancel Ratum to Questions 1 4 ribera Te sp Ihn PROS d yim m ee onda relata Due ced Faphaeal be nd hall Gey Dip eed er ices i prec ipu wr ee daba Lieu 01d 2004 Peer Paces Salery Authority Ali nghe ceed 41 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS There are follow up questions associated with Event Type W Capacity The two 2 new questions are Where are patients receiving care as a result of the capacity problem e g ED PACU hallway o The response will be free form text How many patients were affected by this event over the one day period covered by this report o The response will be a 2 digit number PA Pennsylvania Patient Safety PSRS Reporting System Event Report Wednesday January 21 2015 Time remaining R set Timer Help Capacity Event Details Questions A Where are patients receiving care as a result of the capacity Requred problem amp g ED PACU hallway o B How many patients were affected by this event over the Required O O one day period covered by this report VERSION 6 5 42 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Screen 4 Event Outcome Questions 9 12 e This screen asks questions about the
150. tes report with state group periodic falls rates comparison data is shown below General Medical Surgical Units Falls Rates vs State General Medical Surgical Units Falls Rates June 2012 to August 2012 PITTTILLLL EL ld Falls Per 1 000 Patient Days Jun Jul Aug M 3812 a General Medical Surgical Units Fals State Periodic Falls Rate Rate State Periadic Falls Rate State Periodic Falls Rate Upper Confidence Leva Lower Confidence Leva M missing data A maximum of 6 facilities are included in the comparison group calculation Each time period is calculated separately and ifs possible that each time period has a different number of facilities that are included in the comparison group calculation The comparison group calculation must have at least 5 facilities to work VERSION 6 5 120 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM A bar graph showing inpatient vs outpatient care area tracking group falls rates with peer group periodic falls rates comparison data is shown below Facility Falls Rates vs Peer Group Facility Falls Rates April 2012 to June 2012 Peer Group Name Acute Care Hospitals over 300 beds REESE eee E E ngn d cc d aUa Wu ma ua Ma Ma Fab a Fa Fa Ma Ma Ma Fa Fg Ma Kx My Hm Eg Mg La auia ge ge y y a ya ya a a a ya y a y a g a y a retenue ieena i p B x TT t E ta
151. that similar cases can be grouped and analyzed together The taxonomy has up to three levels with each level becoming more specific For example a report may be of a Medication Error Level 1 Involving what kind of medication error Monitoring error Level 2 where the specific error was Documented allergy Level 3 This would be the Event Type for reporting a case where a patient received or nearly received a medication to which they had a documented allergy assuming it otherwise met the definition of a Serious Event or Incident At the highest level Level 1 there are 16 Event Types labeled A through X Medication Error Adverse Drug Reaction not a medication error Equipment Supplies Devices Fall Error Related to Procedure Treatment Test Complication of Procedure Treatment Test Transfusion Skin Integrity Patient Self Harm Other Miscellaneous Emergency Services Response Physical Plant Utilities Service Disruption Administration Management Criminal Potentially Criminal or Illegal Activity Capacity Other Infrastructure Failure xzxdogc rommoomr Event Types A through may apply to both Serious Events and Incidents Event Types R through X are reserved for Infrastructure Failures The complete Event Type taxonomy is presented in Appendix B Categories A and E use the word error The use of this word is not meant to convey blame or guilt associated with these events The use of the wo
152. the VA s SAC method each patient safety event i e a Serious Event or Incident can be assigned a risk assessment score which is derived by locating the intersection of the severity and frequency estimates The higher the score the greater is the risk associated with the event An advantage of this system developed by the VA s National Center for Patient Safety over the NCC MERP system is that it recognizes that some near misses are more significant than some actual events For example nearly administering a drug to which a patient has a known serious allergy is more significant than actually failing to administer a Tylenol When answering Questions 11 and 12 clicking on Definitions will bring up guidance on how to choose among the categories available for each question see Figure 5 1 67 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE REPORT CODING Figure 5 1 Definitions for VA Severity Assessment Code Questions 11 and 12 Likelihood Frequent Likely to occur immediately or within a short period of time may happen several times in 1 year Occasional Probably will accur in time may happen several times in 1 ta 2 years Uncommon Possible ta occur in time imay happen sometime in 7 ta 5 years Remote Unlikely to occur may happen sometime in 5 ta 30 years Severity Catastrophic Patients with actual or potential Death or major permanent lass offunction sensory m
153. the delivery of additional health care services to the patient The term does not include an Incident Incident An event occurrence or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient The term does not include a Serious Event Infrastructure Failure An undesirable or unintended event occurrence or situation involving the infrastructure of a medical facility or the discontinuation or significant disruption of a service which could seriously compromise patient safety Infrastructure Structures related to the physical plant and service delivery systems necessary for the provision of health care services in a medical facility Other event An event for fulfilling the Centers for Medicare amp Medicaid Services CMS requirement of hospitals to report any death in restraints or seclusion or in which restraints or seclusion were used within 24 hours of death other than soft wrist restraints e Figure 1 1 Key Definitions Important Note As used in this manual or in the PA PSRS software application the word event is a generic term to describe any actual or potential patient safety related occurrence In this 1 44 Pa Bull 6178 Sept 27 2014 Final guidance for acute healthcare facility determinations of reporting requirements under the Medical C
154. the distribution of second level event types for each event type category as well as the distribution of harm scores among those reports For example under the event type Skin Integrity this report presents a how many or what proportion of reports relate to pressure ulcers rashes lacerations and burns etc and b how many or what proportion of skin integrity reports fall into each harm score category To see the subcategory distributions for different first level event types e g medication error skin integrity etc after generating the report select different Event Types using the dialog box above the graph or chart area From the main report selection page you can choose to show any combination of report types Serious Event Incident or Infrastructure Failure By selecting Additional Criteria you can modify the report by event date gender or age of affected patients care area or event type In addition to showing your facility s data this report also presents aggregate statewide data for comparison 79 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE PA 4 Pennsylvania Patient Safety EE E E anne PSRS Reportin System Organization Trainin Distribution of Sub Categories Selection Criteria Report Style Report Submission Type V Serious Event V Incident V Infrastructure Failure Event Date Current Year Gender All Age All Care Area All Event Type
155. the rates of falls and falls with harm 2 Facility level monthly data only no unit level Yes agree to standardize my facility s definitions and reporting of falls and to provide monthly utilization data i e patient days at the Facility level this will allow for facility level detailed reports of the rates of falls and falls with harm understand that will NOT be able to generate unit level reports 3 Noenrollment No choose not to participate in the standardized reporting of falls understand that will NOT be able to generate reports of the rates of falls and falls with harm To save your enrollment selection click the Save button at the bottom of the screen a pop up window with an enrollment confirmation message will confirm your selection To confirm this selection click the OK button To change the selection identified in the enrollment confirmation pop up window click on the Cancel button to return to the Enrollment Options screen and select a different enrollment option Message from webpage o You are enrolled in the standardized reporting of falls program at the P UNIT level By choosing this option you are required to enter monthly UNIT level utilization data You will be able to obtain falls reports at the Unit and Facility level To accept this option click OK To change your enrollment status click Cancel To cancel the current falls program enrollment selection and default to the last
156. this time ze When you do click OK you will see the screen shown below which confirms that your report has been submitted The report will be assigned a unique Report Number which you can record You will also have the option to print out a summary of the report you just submitted or immediately begin to enter a new event report PA i Pennsylvania Patient Safety Q Reporting System Organization Training Facili Help The submission process has been successfully completed This report has been sentto the PA Department of Health For your records the Report Identifier associated with this submission is 49530 Thank you What would you like to do next Print This Report Add another Event Report Return to Main Page NS Logoff 49 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Report Submission Other Events CMS requires hospitals to report any death in restraints or seclusion or in which restraints or seclusion were used within 24 hours of death other than soft wrist restraints Submitting Other reports follows the same format as the submission of Infrastructure Failure reports You must be logged onto the system as a PA PSRS User as opposed to the Facility System Manager and Read Only User The screens are NOT identical to the screens for Incidents and Serious Events RESPONSES ARE REQUIRED FOR ALL QUESTIONS though Not Applicable is
157. tient care areas as defined in PA PSRS e g emergency room rehabilitation services radiology etc The daily count should INCLUDE inpatients and outpatients who receive services in these areas Utilization Data Entry PA PSRS Users are responsible for submitting utilization data If you are a Read Only User you will be unable to submit data or reports The Facility System Manager is responsible for assigning User versus Read Only rights When the PA PSRS User logs in to PA PSRS the blue horizontal Navigation Bar will appear as below To access the utilization data entry screen select the Utilization Data menu option from the Navigation bar If you are enrolled in the unit level falls reporting program the unit level utilization data screen will appear If you are enrolled in the facility level falls reporting program the facility level utilization data screen will appear Both the unit level and facility level utilization data entry screens have the same two links a help link and a definitions link see utilization data screens below The Help link is located in the upper right hand corner of the screen It will open to this section of the PA PSRS user manual that pertains to entering utilization data The Definitions link is also located in the upper right hand corner of the screen This link will provide an informational pop up screen with the definitions for Patient Days and Patient Encounters VERSION 6 5 97 JUNE 2015
158. tilization data i e patient days and patient encounters atthe UNIT level this will allow for unit level and facility level detailed reparts of the rates af falls and falls with harm T see the units care areas that your facility would need to supply data for on a monthly basis press the Falls Units button below C Facility Level Monthly Data no unit level Yes agree to standardize my facility s definitions and reporting of falls and to provide monthly utilization data i amp patient days at the FACILITY level this will allow for facllity evel detailled reports of the rates of fails and falls with harm understand that will NOT be able to generate unit lavel raparts No Enrollment No I choose not to participate in the standardized reporting of falls understand that I will HOT be able to generate reports of the rates of falls and falls with harm Fals Unts Showhistoy save Cancel VERSION 6 5 94 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM VERSION 6 5 The Enrollment Options screen will display three falls reporting program participation options from which to select 1 Unit level monthly data Yes agree to standardize my facility s definitions and reporting of falls and to provide monthly utilization data i e patient days and patient encounters at the Unit level this will allow for unit level and facility level detailed reports of
159. tion Event Detail by Harm Score Distribution of Sub Categories Top3Event Types by Care Areas High Alert Medications and Steps In The Medication Process Falls Rates Facility Report Falls Risk and Strategy Process Measure Falls Dashboard Falls Utilization Data Report Details Related to Falls Medications Contributing To Risk For Fall Distribution of Potential Contributing Factors JCAHO National Patient Safety Goals m e Unit level enrolled hospitals will have access to the falls rates report falls rates report for inpatient vs outpatient care areas falls risk and strategy process measure report falls dashboard falls tracking group rates report and falls utilization data report VERSION 6 5 107 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Report Selection Falls Rates Report Inpatient vs Outpatient Care Areas Falls Risk and Strategy Process Measure Falls Dashboard Falls Tracking Group Rates Report Falls Utilization Data Report Jelg Related t Fa Medications Contributing To Risk For Fall Distribution of Potential Contributing Factors n Configurable Options The reports have configurable options that vary according to the type of falls report and enrollment level If a report is selected and the Generate Report button is clicked the default settings for that report will apply If a customized report is desired click
160. tps edsegov01 Admin selec ER P S R gt Reporting system Select a new date range then click proceed Help Main Page Event Report Utilization Data Start Date 09 01 2005 EAE mmaa Wednesday September 14 2005 Organization Training Facili Date Range 09 01 2005 to 09 14 2005 new date range End Date 09 14 2005 CS Showing 1 20 of 22 Total Records 09 14 2005 HE mmddyy Selected Report ID Report ID TBD Report Type CareArea Event Ty amp Time M ed Td Td Td T T T 49530 Infrastructure Test Care Area 11 X Other Infrastructure 22 9 13 2005 15 04H 49520 Infrastructure Test Care Area 11 R Emergency Service 41 9 13 2005 15 02H 49511 Serious TestCare Area 11 A Medication error L ot 22 9 13 2005 14 47H 49469 Incident TestCare Area 12 E Error related to Procedure C 89 TT 3 2005 Unknown 9 13 2005 13 34H Treatment Test To find a specific report when you already know the ID number select Event Report from the menu bar then select Retrieve Event Report by Report ID This will take you to the screen shown below Enter the Report ID and press Retrieve Report VERSION 6 5 59 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS PA K Pennsylvania Patient Safety Tiiesday September 13 2005 Reportin system Organization Training Facili Retrieve Event Report by Report ID Enter Specific Report ID Exclude Amen
161. ts Infrastructure Failures and Other events 3 Amending submitted reports 4 Data analysis of submitted reports User Roles Each facility will have three system roles e Facility System Manager e PA PSRS User e Read Only PA PSRS User Each role has unique responsibilities and separate User IDs and passwords The first role the Facility System Manager is responsible for e Assigning user IDs and passwords to other users in the facility and conversely removing user IDs and passwords e Establishing and maintaining care areas that will help define the location of events within a facility e Enrollment in the Falls Reporting Program See the chapter Facility Management for steps the Facility System Manager must take before using the system for the first time The second role is that of a PA PSRS User One person may serve as both a PA PSRS User and the FSM or a facility may designate a different person for each role A PA PSRS User is responsible for e Submitting reports e Amending reports VERSION 6 5 7 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE GETTING STARTED e Viewing and printing reports e Analyzing data from the system Each MCare covered facility designates its own Patient Safety Officer PSO in its Patient Safety Plan as submitted to the Department of Health under MCare The PSO will be the primary point of contact responsible for interacting with PA PSRS A
162. unit pediatric unit etc This includes any patient who is formally admitted while in the emergency room and is being held while waiting for a room Outpatient e Any patient who receives care in the hosptal without being admitted e q emergency room rehabilitation services radiology This definition includes emergency room patients prior to formal admission anc emergency room observational patients This EXCLUDES any patient who is formally admitted while in the emergency room and is being held while wating for a room It also includes patients who receive care n an ambulatory surgical facility birthing center and abortion facility Unknown Patients designated as unknown are assumed to be either inpatient or outpatient based on the reported location where the event occurred including falls for the purpose of calculating falls rates Close There are three patient status choices The patient status field is used in calculating falls rates reports Limiting the use of the Unknown field will improve the accuracy of falls rates reports Inpatient any admitted patient including observational patients that receive care in a hospital unit e g medical surgical unit critical care unit pediatric unit etc This includes any patient who is formally admitted while in the emergency room and is being held while waiting for a room Outpatient any patient who receives care in the hospital without being admitted e g emergency
163. uted to or resulted in temporary harm and required treatment or intervention An event occurred that contributed to or resulted in temporary harm and required initial or prolonged hospitalization G event occurred that contributed to or resulted in An event occurred that contributed to or resulted in permanent harm harm event occurred that resulted in a near death event e g required EE care or other intervention necessary to sustain life Event Death a j An event occurred that contributed to or resulted in death Source Adapted from the National Coordinating Council on Medication Error Reporting and Prevention 66 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE REPORT CODING Helpful Hint Use the Harm Score to distinguish between Serious Events and Incidents The Harm Score measures the extent to which a patient safety event reached the patient and also the severity of the consequences of the event for the patient In PA PSRS a Harm Score of D or below is consistent with an Incident while a Harm Score of E or above defines a Serious Event Severity Assessment Code VERSION 6 5 The Severity Assessment Code SAC system for coding patient safety reports is incorporated in PA PSRS as Questions 11 and 12 which ask you to estimate the e Likelihood of event s reoccurrence e Severity of effect resulting from reoccurrence of event Therefore this system rates a report
164. vent from a healthcare worker PA PSRS will notify you of the receipt of the report and request the results of your investigation pursuant to MCare Patient Safety Advisories The Patient Safety Authority and the PA PSRS Program staff issue Patient Safety Advisories with supplements as necessary to facilities and providers Based on actual reports submitted through PA PSRS Aavisory articles include clinical guidance that will be useful as part of your ongoing quality improvement and patient safety activities The Advisories are distributed electronically to all PA PSRS users and are also available on the Patient Safety Authority website at http www patientsafetyauthority org Click on Advisories in the left hand navigation menu Patient Safety Recommendations VERSION 6 5 The Patient Safety Authority may periodically issue recommendations to facilities consistent with MCare with the approval by the DOH These recommendations may be made on a facility specific or statewide basis for the purpose of reducing the number and severity of Serious Events and Incidents 92 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Program Announcements and System Administration The PA PSRS Program periodically distributes program announcements via e mail and via posting on the Authority website http Awww patientsafetyauthority orghttp patientsafetyauthority org concerning
165. will be prompted after the password update Password Validation Requirements VERSION 6 5 1 User password values must contain characters from all of the following four 4 classes e Upper case letters A Z Lower case letters a z Westernized Arabic numerals 0 9 e These specific non alphanumeric characters 9 lt Spaces are not permitted 2 Examples of acceptable passwords using the 4 classes of characters are displayed on all password change screens These sample values are not allowed to be used 3 Passwords must be changed every sixty 60 days 4 Passwords must contain at least eight 8 characters 12 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE GETTING STARTED 5 The previous ten 10 changed passwords are restricted from use 6 Passwords may only change once every two 2 days PA PSRS help desk administrators can reset passwords at any time 7 The password help documentation on the Change Password screen contains the new password policy 8 Accounts will be locked out after eight 8 unsuccessful logon attempts FSM users will have the ability to unlock their facility users from the current user administration screen via checkbox All others must contact the helpdesk When an account is locked out a message to contact the Facility System Manager or the help desk to unlock the account will be presented on screen oee Program Memo
166. wing 1 Which Health IT system s caused or contributed to the event check all that apply A Values Use multiple response categories from AHRQ Common Formats V1 2 Question 21 23 e For each question include an option for Unknown and Other Please Specify if they are not already indicated by the question in the source document B At least one question response is required for all events 2 HIT Contributing Factors check all that apply A Values Use categories taken from the AHRQ Common Formats V1 2 Questions 24 26 e For each question include an option for Unknown and Other Please Specify if they are not already indicated by the question in the source document B At least one question response is required for all events 3 System identifiers A Values o Device Application Name e g Powerchart o Manufacturer e g Cerner o Unknown B Both Device Application Name and Manufacturer values are required unless Unknown is checked VERSION 6 5 30 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Pennaytvorio Patient Sofety Tum Coupe 2 X74 PSRS Rey LI L Mah 1T m7ran LA Cold Frag T cnt mr ar m ur eee 0 Yu l ys C Oden A Timb Mouth T Ppi Comed a Cubed t he Loma check ad oar apis BE T TT Ci Matau getes he dang nira Tua Colnghileq ma Pd U Pe Other Fem Speech pa oO Wlectrssds beak record E FK sr compere of HE Fa Capim pai ode entry CPOU
167. y and amending or adding to their description to reflect any follow up investigation you may have performed NOTE DO NOT INCLUDE THE NAME OF ANY PATIENT OR HEALTHCARE WORKER IN YOUR DESCRIPTION e Question 10 asks you to select a harm score which measures a the extent to which the event reached the patient and b the degree of harm the event caused to the patient This harm score is adapted from a system developed by the National Coordinating Council for Medication Error Reporting and Prevention NCC MERP See Chapter 5 for more detailed discussion of the harm score and how to interpret it e Questions 11 and 12 ask you to identify the likelihood of the event s reoccurrence and the likely severity of the event should it reoccur These questions together form the basis of a severity assessment index a tool for prioritizing reports for special attention or analysis Help in answering these questions is available by clicking on Definitions These questions and the criteria for answering them are based on the Severity Assessment Code system developed by the Veteran s Administration s National Center for Patient oafety Please think carefully about the code that you use as these codes also help us to focus our attention on the most important reports e Click Next Page when finished VERSION 6 5 28 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS x a Tuesday September 13 2005 P
168. y 24 2012 PSRS Reporting System Time remaining EIE Reset Timer Help Event Report Organization FALLS HSP K 5 Location Where Event Occurred 6 Date Of Admission Or Date Of Ambulatory Encounter Date mm dd yyyy ac 6a Patient Status E Inpatient C Outpatient Unknown Definitions T EventDate And Time Date mm dd yyyy a Time hh mm s Time Unknown Ta Confirmation Date Date mm dd yyyy Bi Tb If You Are Submitting This Report More Than 24 Hours After Confirmation Please Explain maximum 500 characters 8 EventType other specify maximum 250 characters Event Type Level 1 Select Event Type Y Sub Category Level 2 Other specify Sub Category Level 3 Other specify Next Page Top of Page Cancel Return to Questions 14 Information submitted via this reporting system is protected under applicable State and Federal law and shall only be used or disclosed in accordance with those same laws 01 2004 Pennsylvania Patient Safety Authority All rights reserved VERSION 6 5 52 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE EVENT REPORTS Screen 4 Event Outcome Questions 9 12 e This screen asks questions about the outcome of the event In Question 9 you are asked to describe the event NOTE DO NOT INCLUDE THE NAME OF ANY PATIENT OR HEALTHCARE WORKER IN YOUR DESCRIPTION e Question 10 asks you to select a harm score the on
169. y of the utilization click the Print button If the Reset button is selected before the Save button any currently entered utilization data will not be saved To close the utilization data screen click the Close button which will prompt the user to save the data if there are changes and then close the screen 99 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE FALLS REPORTING PROGRAM Amending Unit level Utilization Data Participating hospitals have the ability to amend their Utilization Data for the previous 3 months To amend utilization data return to the Navigational Bar screen where you will see a drop down box with menu choices Select Edit Utilization Data from the Utilization Data menu Utilization Data Enter New Utilization Data Edit Utilization Data CUTPCHTCU cren The amending utilization data screen will be the same as the data entry utilization data screen except there will be drop down menus for the year and month Data for the most recent month will be displayed To edit data for a different month select the month for the data that you wish to modify from the drop down menus VERSION 6 5 100 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE Enter Unit Level Utilization Data for January 2012 Or Select the Month to Edit Inpatient Care Area Inpatient Care Unit Surgical Services Unit Level Patien
170. you want by clicking on the name and then by clicking on the Generate Report button in the bottom right corner of the page Alternatively you can set other parameters for your report by clicking on the Additional Criteria hyperlink VERSION 6 5 74 JUNE 2015 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA ANALYSIS Types of Analytical Reports Summary of Submitted Reports by Type This report presents a simple table showing the number of Serious Event Incident and Infrastructure Failure reports submitted by your facility compared with the total number of each type of report submitted by facilities statewide The default timeframe for this report is to calculate all data for the current year By clicking on Additional Criteria you can adjust the timeframe by years months and quarters PAS Pennsylvania Patient Safety necis Setter 100 Organization Training Facili PSRS Reporting System Help Summary of Submitted Reports by Type Selection Criteria Event Date Current Year Select New Criteria Choose New Report Return to Main Page Facility PA PSRS Report Submission Type Facility Statewide Aggregate Serious Event 23 11 3 11 3 ls Incident 169 83 3 83 3 Infrastructure Failure 11 5 4 5 4 Total 203 100 100 Select New Criteria Choose New Report Return to Main Page JUNE 2015 VERSION 6 5 75 PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM TRAINING MANUAL AND USERS GUIDE DATA
171. ys will often be higher than the sum of the patient days entered for the individual units This is because there are inpatient days occurring on units that are not part of the falls reporting program tracking groups e g women s health mother baby The total facility level patient days will equal the sum of the units in smaller hospitals where all inpatient days occur on units that are part of the falls reporting program tracking groups Notice two shaded rows Patient Days Subtotal sum of patient days from units above and Patient Days from Other Units calculated as difference between Facility Level Patient Days and Unit Level Patient Days Subtotal The PA PSRS system will automatically calculate this data Outpatient Patient Encounters In the third column of the second table titled Patient Encounters enter the number of patient encounters for the month in the box next to each of your institutions designated facility outpatient care areas Notice the shaded row Total Patient Encounters Selected Units Above The PA PSRS system will automatically calculate this data NOTE The facility level OUTPATIENT fall rate will be based SOLELY on those units where there is denominator data Falls that occur in any outpatient units not being monitored for utilization data will be excluded from the falls rates reports When finished entering the utilization data click the Save button at the bottom of the screen To print a hard cop

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