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A Patient Safety Network: Proposal from the DHHS Patient Safety Task Force for Stakeholder Consideration. Julie Louise Gerberding, MD MPH Division of Healthcare Quality Promotion National Center for Infectious Diseases Centers for Disease Control and Prevention. A Safety Network: Vision.

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A Patient Safety Network: Proposal from the DHHS Patient Safety Task Force for Stakeholder Consideration

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A patient safety network proposal from the dhhs patient safety task force for stakeholder consideration

A Patient Safety Network: Proposal from the DHHS Patient Safety Task Force for Stakeholder Consideration

Julie Louise Gerberding, MD MPH

Division of Healthcare Quality Promotion

National Center for Infectious Diseases

Centers for Disease Control and Prevention


A safety network vision

A Safety Network: Vision

The safety network is a knowledge system for accumulating, exchanging and integrating relevant information and resources among private and public stakeholdersthat support local efforts to protect patients and promote healthcare safety.


A safety network proposed goals

A Safety Network: Proposed Goals

  • Improve safety by creating and disseminating knowledge necessary to detect and respond to current and emerging healthcare safety threats

    • Monitor the cause, frequency and impact of targeted safety events

    • Establish priorities for safety promotion programs

    • Disseminate lessons learned

  • Protect confidentiality

  • Reduce reporting burden and ensure local access to healthcare safety information

  • Monitor progress toward achieving local, state, and federal patient safety goals


A safety network proposed concepts

A Safety Network: Proposed Concepts

  • Knowledge system for patient safety is essential

  • Local user relevance is essential

    • value-added to local and state patient safety programs

    • decrease reporting burden; easy to use

    • protect confidentiality

  • System integration is essential

    • include state / federal required reports

    • employ standardized methods / definitions / lexicon

    • build from existing data system standards (e.g. National Electronic Disease Surveillance System - NEDSS)

    • compatible with existing systems

  • Modular system is optimal

    • evolution and evolution over time


A safety network proposed information content

A Safety Network: Proposed Information Content

  • Prevention tools / lessons learned / best practices

  • Incident reports: targeted adverse events or near misses where “zero events” is the goal

    • “Never” events (e.g. “wrong limb” surgery)

    • Sentinel events that signal a need for immediate response and root cause analyses

    • Unusual events that might reflect preventable threats to patient safety and deserve investigation

  • Rates: “best possible rate” and continuous improvement is the goal

    • Benchmarks (e.g. device-associated complication rate)

    • Performance measures

    • Trendsover time


Safety network sample architecture and integration

Web Portal

(Common

User

Interface)

Federal

Agencies

Shared

De-Identified

Data Warehouse

States &

Other non-federal

Stakeholders

Users

  • Users

  • Providers / Administrators

  • Hospitals

  • Clinics / Outpatient Care Facilities

  • Long Term Care Facilities

  • Home Care Agencies

  • Health Plans

  • Consumers

  • Other Stakeholders

  • State / Local Health Departments

  • Peer Review Organizations

  • Other Contractors

  • ? Accreditors

Data Repositories

Safety Network: Sample Architecture and Integration


Proposed safety network with expansions

Non-federal

Data Systems

not linked to network

Proposed Safety Network with Expansions

State and non-federal Stakeholders

Federal

Agencies

Web Portal

(Common

User

Interface)

Users

Shared

De-Identified

Data

Warehouse


Scenario patient safety in dialysis units

Scenario:Patient Safety in Dialysis Units

  • In conjunction with many partners and stakeholders, HCFA, FDA, CDC, and AHRQ have responsibility for promoting dialysis patient safety

  • All 3 types of data proposed for the Safety Network are relevant:

    • Prevention tools / best practices / lessons learned

    • Incidents: e.g. access catheter malfunction; water quality failure

    • Rates: e.g. access infections, hospitalizations


A patient safety network proposal from the dhhs patient safety task force for stakeholder consideration

Dialysis Unit Safety Network


A patient safety network proposal from the dhhs patient safety task force for stakeholder consideration

Table 3. Reported Incidents, Center 999999

Patient ID Date Access InfectionThrombosis Admission ?

463 10/02/2000 Fistula 1 - N

912 11/08/2000 Temp Cath Y

18112/01/2000 Graft 1- Y

11212/06/2000 Temp Cath1 Y

10312/07/2000 Temp Cath1- N

11112/09/2000 Temp Cath11 Y

18112/11/2000 Temp Cath 1- Y

Note: Center 999999 does not exist; data developed for

illustration only


A patient safety network proposal from the dhhs patient safety task force for stakeholder consideration

Dialysis Unit Safety Network


A patient safety network proposal from the dhhs patient safety task force for stakeholder consideration

Dialysis Unit Safety Network


A patient safety network proposal from the dhhs patient safety task force for stakeholder consideration

Dialysis Unit Safety Network


Safety network sample architecture and integration1

Web Portal

(Common

User

Interface)

Federal

Agencies

Shared

De-Identified

Data Warehouse

States &

Other non-federal

Stakeholders

Users

  • Users

  • Providers / Administrators

  • Hospitals

  • Clinics / Outpatient Care Facilities

  • Long Term Care Facilities

  • Home Care Agencies

  • Health Plans

  • Consumers

  • Other Stakeholders

  • State / Local Health Departments

  • Peer Review Organizations

  • Other Contractors

  • ? Accreditors

Data Repositories

Safety Network: Sample Architecture and Integration


Next steps

Next Steps

  • Modify conceptual model of Safety Network based on input from participants at this summit

  • Implementation contract for network development

  • Stakeholders meeting to specify actual content of initial data collection modules

  • Fast track to pilot


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