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State of Utah Patient Safety Initiatives - PowerPoint PPT Presentation


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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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Presentation Transcript
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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