Importance of Reporting
According to the Joint Commission,
“Identifying and reporting unsafe conditions before they can cause harm, trusting that other staff and leadership will act on the report, and taking personal responsibility for one’s actions are critical to creating a safety culture and nurturing high reliability within a health care organization.”
Reporting safety events and
near-miss events consistently
maintains the reporting relationship that is required for members with written
agreements in place to receive the confidentiality and privilege protections offered by PSOFlorida.
- Meaningful data aggregation and analysis.
- Identification of trends and patterns in various types of events and levels of harm when applicable.
- Support the development of
educational materials for
members based on reported
events to assist with driving
quality improvement
initiatives.
Click on the link here to access the Joint Commission Sentinel Event Alert 60: Developing a reporting culture: Learning from close calls and hazardous conditions.
What to Report
report safety events that are near-misses or
that actually reach the patient, whether they
cause harm or not, in order to learn as much as
we can about the care environment and how
to mitigate safety risks. Regular reporting to
PSOFlorida is important because it allows us to
share learning about events with our members,
and it protects members’ patient safety work
product from legal discovery so that lessons
learned for improvement can be shared in a
safe and protected environment.
- Circumstances or events that have the
capacity to cause error. - A near event (also known as a good catch or
near miss). - An event that reached the patient but did not cause harm.
- An event that reached the patient and caused
some level of harm (temporary or permanent). - An event that resulted in patient death.
One of the purposes of a PSO is the collection, analysis and reporting of patient safety data. A standardized patient safety system is an important mechanism for enhancing knowledge about the errors and their underlying causes. The patient safety system implemented by the PSOFlorida will help Florida hospitals learn from the experiences of others and share their own. PSOFlorida uses a Web-based patient safety reporting system to capture patient safety data in a standardized manner compatible with AHRQ’s common formats, the National Quality Forum (NQF): Serious Reportable Events (SRE), and the CMS hospital-acquired conditions. By aggregating and analyzing data that is collected with a common format, PSOFlorida will
improve the comparative and longitudinal analysis of data and find common patterns that will lead to intervention and ultimately achieve the goal of preventing harm.
Through this secure portal, PSOFlorida has aggregate de-identified data available for all participating hospitals and an additional set of de-identified data from a larger national data set. This will allow PSOFlorida and Florida hospitals the ability to immediately analyze and evaluate the reported data from both a state and national perspective. All data reported to the PSOFlorida will be strictly confidential and data will be held to the same standard for information submitted to a peer review process. No patient information or information regarding the clinician or hospital employee reporting the event will be disclosed.
The secure portal can also be used for manual event reporting. Since October 2023, members of PSOFlorida can now submit an event through the new and improved manual event reporting process!
The new event entry system offers a quick and easy way to submit adverse events, near misses and unsafe conditions to the PSO for protection and shared learning under the Patient Safety and Quality Improvement Act of 2005.
The new reporting system functions in any web browser and does not require the download of any software.
Events can be viewed on the PSO dashboards one day after entry for all users who have access to the PSO dashboards.
