In December 2006 and January 2007, the Patient Safety Authority hosted several small discussion groups of Patient Safety Officers (PSOs) from Pennsylvania healthcare facilities. Meetings were held across the state, and a representative group of 26 PSOs participated. The purpose of the meetings was to: give the Authority insight on how PA-PSRS can best help PSOs to improve patient safety, understand PSOs’ needs and challenges, and seek feedback on the current and future direction of PA-PSRS.
The Authority benefitted tremendously from an open and thoughtful dialogue with participating PSOs, and the ideas and opinions offered at these meetings have informed the Authority’s Board of Directors in their strategic planning. A full report on the discussions, A Conversation with Patient Safety Officers, is available on the Authority’s Web site.
Among the topics PSOs raised as potential areas for the Authority’s assistance are:
- Helping to educate senior administrators and Boards of Trustees in how they can demonstrate leadership in their facilities and promote patient safety
- Augmenting PSOs’ limited time and resources by helping to educate front-line clinicians in patient safety
- Clarifying the reporting requirements in the Medical Care Availability and Reduction of Error (Mcare) Act and promoting greater standardization across facilities
- Providing guidance on disclosure of Serious Events to patients
The PSOs participating in these meetings also expressed interest in working with the Authority and with one another in workgroups and collaboratives to address a variety of patient safety initiatives. In a sense, PA-PSRS is itself a large, virtual collaborative. By continuing to report the adverse events and near misses that occur in your facility, you are helping to spread that knowledge through the Patient Safety Advisory. In our recent annual survey of PSOs, you and your colleagues throughout the state told us about hundreds of changes you had made as a result of articles in the Advisory. You also gave us high marks for the Advisory’s quality and relevance.
Yet, we also learned in these discussion groups that there is much more we could do to help you improve the safety of the care you provide. Over time, you should expect to see the Authority providing new opportunities for collaboration across facilities. One example is the PA-PSRS Workgroup on Pharmacy Computer System Safety, in which 32 hospitals tested their pharmacy computer systems against a set of unsafe medication orders, to see if their systems would detect them. Another example is the workshop “Failure Mode and Effects Analysis (FMEA) in Patient Safety,” which the Authority is offering in May and June 2007.
We look forward to providing similar programs in the future, and we encourage you to participate in them. As one Patient Safety Officer stated in our discussion group meetings, “Patient safety is probably the one area where we would all agree that we should be cooperating and not competing.”