Patient Safety Net Training for Research Staff September
Patient Safety Net Training for Research Staff September 2018 Table of Contents Use of Patient Safety Net at SCCA 1 2 3 Patient Safety Net Access Navigating Through PSN QI work product CONFIDENTIAL & PROTECTED pursuant to RCW 4.24.240-250 & RCW 70.41.200
What is Patient Safety Net (PSN)? PSN is an anonymous online reporting system used at the Seattle Cancer Care Alliance. PSN is used by the Quality Department to track events that occur at the SCCA such as: Unsafe Conditions: Environmental factors or work processes that have a potential to harm a patient. Near Misses: Events that do not reach the patient but had the potential to harm or inconvenience the patient if it had not been corrected before reaching the patient. Events that Reach the Patient: Events that reach the patient causing harm or inconvenience. Research Integration leverages PSN to monitor events involving research participants in order to identify protocol noncompliance as well as Near Misses that could have resulted in noncompliance had the event not been corrected by someone (clinic or research staff). QI work product CONFIDENTIAL & PROTECTED pursuant to RCW 4.24.240-250 & RCW 70.41.200
Use of Patient Safety Net at SCCA The Role of PSN at the SCCA Learning from Events, Near Misses, and Unsafe Conditions is key in monitoring and improving our process for safety and efficiency. A system flaw or gap can go undetected without your PSN report. When an error occurs, the review often uncovers system vulnerabilities that could be improved upon. Learning from PSN events helps the SCCA build better systems to promote patient safety and support your work. The ultimate goal is to protect patients from harm. Examples of Research Related PSN Event types: Omission/errors in assessment, diagnosis, monitoring Assessment issues, missed monitoring
Laboratory Test Specimen collection and/or processing issues Communication/Care Coordination Problems Scheduling Issues Unclear or incomplete orders Medication related Incorrect completion of orders, issues with duration of infusion
Prescription/refill or IV drug delay QI work product CONFIDENTIAL & PROTECTED pursuant to RCW 4.24.240-250 & RCW 70.41.200 PSN Account Access All staff (including affiliates) have the ability to enter a PSN. Access to PSN is granted by using your UW AMC/IRIS Logon information (also known as your Orca/Mindscape password). If you do not have an AMC account, work with your manager to fill out the PSN access request in the UAA form. PSN is accessed via the link: https://patient.seattlecca.org/psn/Pages/info.aspx QI work product CONFIDENTIAL & PROTECTED pursuant to RCW 4.24.240-250 & RCW 70.41.200 Patient Safety Net Access
Entering an Event PSN Icon is located on all SCCA Clinic Desktops and identified by this icon Research Staff not in the SCCA Clinic can access PSN via the following Link (saved to favorites or manually as a link on desktop): https://sslvpn.medical.washington.edu/ and use this document for steps on how to VPN into the system QI work product CONFIDENTIAL & PROTECTED pursuant to RCW 4.24.240-250 & RCW 70.41.200 Patient Safety Net Navigation How to VPN to Patient Safety Net Select https://sslvpn.medical.washington.edu/dana-na/auth/url_default/welcome.cgi Login with your
AMC credentials In the upper left corner select the UWMC Intranet On the intranet page, scroll to the bottom and select Patient Safety Net (PSN) from the list of Top Tools: Login to PSN using your AMC account Concepts to Remember When Entering an Event for a Research Patient The intent of PSN reporting is to track system issues in patient care, vs. finger pointing/blame on people. To be of the most benefit, events should be entered within a day of the occurrence.
When entering an event, be as objective as possible. Enter Research Patient as the first two words in the event description. Bonus: Include the protocol number the patient is on. Bonus: Indicate if there will be other reporting requirements (e.g. sponsor, IRB) Bonus: Identify if clinical decision-making was impacted by the event. QI work product CONFIDENTIAL & PROTECTED pursuant to RCW 4.24.240-250 & RCW 70.41.200 Patient Safety Net Navigation The Life of a PSN Event or Near Miss Occurs and Event Entered by Front Line Reporter
Online Event Entry Ancillary Manager if specific event type (ie. Falls, Transfusion events) Department Manager where event occurred Immediate Email
notification of new event is triggered to: Pharmacy Manager (if Medication Error) Quality Manager (All Event Types) Lab Quality Manager (If Lab Event)
CTP Quality Manager (Product Related Events) Risk Manager (Disruptive Behavior or Care Contract) Sends consultation to additional managers for feedback if needed Event Review
NOTE: Managers can be Physicians, Pharmacists, Nurse Managers, Lab Managers, Manager Reviews event, documents any follow up, and submits. QI work product CONFIDENTIAL & PROTECTED pursuant to RCW 4.24.240-250 & RCW 70.41.200 Quality Manager Does final review of event and all manager reviews, closes event.
Patient Safety Net Navigation Need Help? For any questions regarding Patient Safety Net contact: Patient Safety: [email protected] QI work product CONFIDENTIAL & PROTECTED pursuant to RCW 4.24.240-250 & RCW 70.41.200
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