State of utah patient safety initiatives
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State of Utah Patient Safety Initiatives. Iona M. Thraen, ACSW. Presentation Outline. Overview – Defining the Problem SE reporting and analysis ADE reporting and analysis Patient Safety Reporting for Consumers Intervening ADE users group SE users group HAI users group

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State of utah patient safety initiatives

State of Utah Patient Safety Initiatives

Iona M. Thraen, ACSW


Presentation outline

Presentation Outline

  • Overview – Defining the Problem

    • SE reporting and analysis

    • ADE reporting and analysis

    • Patient Safety Reporting for Consumers

  • Intervening

    • ADE users group

    • SE users group

    • HAI users group

    • Perinatal Mortality and Morbidity Review


Overview community coalition

Overview – Community Coalition

Utah Health Data Committee

SB132 Task Force

Maternal and Infant

Mortality Review

Committee

(proposed)


Overview

Overview

  • IOM Report 1999 – To Err Is Human

    • State Administrative rule - October 15, 2001

      • SE reporting rule

        • Voluntary reporting, RCA, and action plan reporting

      • ADE reporting using administrative data

        • Health Data Committee – Hospital discharge data

        • 3 year audit for ADE reduction program

    • AHRQ grant

    • VA/AHRQ team training

    • State absorption of responsibilities

  • Law: SB132 mandates Utah Health Data Committee to release comparative reports on patient safety, quality and charge for consumer audience

  • Law: HB132 Pain Medication Management and Education $150,000 for two years.


Overview continued

Overview Continued

Partnership between UDOH, UHA, UMA, and Health Insight (QIO)

  • Patient Safety Guidance Council

  • SE Users Group

  • ADE Users Group

  • HAI Users Group

  • Perinatal Review Committee


Overview continued1

Overview Continued

  • Statewide Philosophies

    • Non Punitive

    • Community Partnerships

    • User driven

    • Administrative guidance

    • Data/evidence based

    • Level playing field

    • Administrative not legislative

    • Accountability

    • Non burdensome


State wide interventions

State-wide Interventions

  • ADE users group –

    • Failure Mode Effects Analysis (FMEA)

      • Anti-Coagulants

      • Insulin

  • SE users group –

    • C³ - Correct Patient, Correct Procedure, Correct Site

  • HAI users group –

    • Rules, Reporting form, WEB site


Patient safety web site

Patient Safety WEB Site

  • http://health.utah.gov/psi/

  • Contact:

    • Iona Thraen, Patient Safety Director

      • HIS/UDOH

      • 538-6471


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