Pennsylvania Patient Safety Advisory Enhancing Patient Safety through Education and Collaboration over each person’s interpretation of the criteria used to distinguish a Serious Event and an Incident. But, working through the scenarios aided the PSOs’ interpretations. One participant said this experience helped her learn “the different ways people report Megan Shetterly, RN, MS events and how to determine the type of event.” Another participant expressed interest in additional Megan Shetterly, RN, MS programs dedicated solely to event reporting. Patient Safety Liaison, Northeast Region Pennsylvania Patient Safety Authority PSOs from ASFs, who represented the majority of participants at the program, discussed appropriate In my encounters with nearly 65 patient safety offi- patient selection for services at an ASF. No clear cers (PSOs) since becoming the Patient Safety Liaison (PSL) for the Northeast Region of Pennsylvania, guidelines identify patient comorbidities or other there is one common theme: the need to collaborate specific criteria that would help to determine which and share in ongoing education about patient safety. setting is the most appropriate for outpatient surgery.1 Patient safety is influenced by many issues in health- Patient selection is typically determined through care, including human factors, high-tech equipment medical screenings performed by the surgeon in and devices, and often dangerous medications and/ consultation with the referring physician and the or procedures. Complex systems of healthcare deliv- anesthesia practitioner. All participating PSOs agreed ery demand the use of evidence-based practices and that comprehensive preoperative screening measures standardization in order to achieve the best clinical capture critical information that can help to deter- outcomes. Ongoing education is necessary to support mine whether a patient is appropriate for the ASF patient safety. setting. For example, if a patient presents to an ASF The Pennsylvania Patient Safety Authority recognizes with an exacerbation of an existing medical condi- that responsibilities and internal support vary for tion that predisposes him or her to harm, that case is PSOs. The Authority is engaged in ongoing efforts to aborted and the patient is transported to a local hos- collaboratively identify and address PSOs’ educational pital for care and treatment. needs. Through the PSL program, the Authority continued its efforts with two recent educational All participating PSOs identified communication offerings. among all providers and patients as a key factor in ensuring a good patient safety program. An example 2009 Patient Safety Officer Foundation discussed by the group was correct-site surgery proto- Education Program cols. Each person in the operating room (OR) plays In early 2009, PSOs in the Northeast Region were a part to ensure not only the correct patient, correct offered a patient safety foundation education course. procedure, and correct site, but to identify potential Eleven PSOs who were either new to their role or complications, procure necessary equipment, and who desired more information about patient safety monitor to ensure proper recovery management. The attended this program. Of the participants, eight were benefits of using forcing functions such as time-out from ambulatory surgical facilities (ASFs) and three checklists were discussed by the group. Some partici- were from hospitals. pants have enhanced their existing OR checklists to The learning objectives of this program included include the World Health Organization’s (WHO) PSOs being able to recall key elements of Chapter 3 of Surgical Safety Checklist. (Information on the WHO the MCARE Act of 2002; recognize their role, respon- Surgical Safety Checklist and accompanying correct- sibility, and scope; identify the components and site surgery information can be accessed via the framework of a patient safety infrastructure; identify Authority’s Web page at http://patientsafetyauthority. how to develop and implement a patient safety plan; org/EducationalTools/PatientSafetyTools/PWSS/ and recognize patient safety challenges. Pages/home.aspx.) A key item of discussion was event reporting—specifi- cally, event determination. This is not unique to this The 2009 Patient Safety Officer Foundation particular group, as other PSOs often struggle with Education Program was well received. The Authority categorizing events that they report to the Author- replicated the program for the South Central region ity. During this particular session, the group had the in June and will take it to other regions in conjunc- opportunity to work through various scenarios and tion with the expansion of the PSL program. The collectively decide its respective event classification. Authority will also build on this success to address In some scenarios, there was debate and controversy more in-depth topics of interest to PSOs. Vol. 6, No. 2—June 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 37 Pennsylvania Patient Safety Advisory MRSA Education Program for Ambulatory facility in which a malignant hyperthermia event had Surgery Centers resolved successfully. The PSO offered to share this An objective of the PSL program is to develop and experience so that others could learn from it. Another conduct educational programs dedicated to the needs PSO offered to share her facility’s medication reconcil- of specific care settings. One of the first Northeast iation process, including policy and forms. Yet another regional sessions involved PSOs of ASFs. was willing to share preoperative assessment forms. The ASFs of the Northeast Region comprise approxi- PSOs also offered topics of interest for future pro- mately 50% of all medical facilities in that region. grams, including correct-site surgery, team building, Although ASFs share some of the same patient safety medication reconciliation, and preoperative screening/ challenges that hospitals and other medical facilities assessment. (See the March 2009 Pennsylvania Patient encounter, ASFs are unique in many ways. Most are Safety Advisory for articles on the first and last topics.) separate and distinct from a hospital setting. ASF All participants were referred to the Authority’s procedures and surgeries are performed on low-risk Web site (http://www.patientsafetyauthority.org) to patients who do not require the more extensive access existing information about these topics and oth- resources available in a hospital setting. In order to ers and were encouraged to provide feedback about obtain/maintain licensure, ASFs must comply with their usefulness. PSOs were likewise encouraged to state standards that differ from state standards for comment on entries to the Authority’s Time-Out in hospitals (e.g., limit of four hours of operating time).2 the OR Competition (entries were reprinted in the In addition, ASFs are accredited by different volun- March 2009 Advisory and are available for comments tary regulatory bodies. While hospitals are accredited by all at http://www.patientsafetyauthority.org/ by the Joint Commission, the majority of ASFs EducationalTools/PatientSafetyTools/PWSS/Pages/ are accredited by the Accreditation Association for scripts.aspx). Ambulatory Health Care. Ongoing Efforts During my visits with PSOs of ASFs, they voiced The Authority’s PSL program will continue to interest about methicillin-resistant staphylococcus communicate with all the medical facilities in the aureus (MRSA). Each PSO understands the core Northeast Region to both identify and respond to infection prevention elements for MRSA, but all are their patient safety needs and initiatives. These and continually looking at best practices for surveillance. future Authority-sponsored educational programs will Regarding patients’ infectious disease status, some offer continuing education hours for Pennsylvania PSOs commented about inconsistent cooperation professional nurses. The programs shared in this arti- from other care settings that transferred patients to cle are among many being planned for the Northeast ASFs for care. Others requested additional education and other regions throughout the Commonwealth. about elements of Act 52 of 2007. As a result, the Those individuals within the Commonwealth who Authority conducted a MRSA education program have an interest in learning about future programs for ASFs on April 7, 2009. The program addressed should contact the Authority. clinical features, mode of transmission, infection pre- vention strategies, recognition of high-risk patients, The Authority is in the process of broadening the surveillance measures, infection control practices, and reach of the PSL program beyond the Northeast elements of Act 52. Region. Two new PSLs will soon engage healthcare facilities within their respective regions of Pennsylva- PSOs from 62% of ASFs in the Northeast partici- nia (see listings under Authority staff on the Advisory pated in this program. PSOs represented various masthead page). Within the next year, it is anticipated types of ASFs (e.g., single procedure versus multiple that the program will grow to encompass three more procedure settings). Overall participant response was regions of the Commonwealth and provide medical quite positive (satisfaction rating of 98%). Evalua- facilities with guidance and education relative to their tion comments reflected that current knowledge was patient safety needs. reinforced, and additional education was provided about items such as the availability of rapid MRSA Notes testing and recommendations from the Centers for 1. Patient screening and assessment in ambulatory surgical Disease Control and Prevention (CDC). The educa- facilities. Pa Patient Saf Advis [online] 2009 Mar [cited tion prompted some PSOs to say that they will modify 2009 Apr 27]. Available from Internet: http://www. facility policies as a result. Another attendee from the patientsafetyauthority.org/ADVISORIES/ Southeast Region, who accompanied a PSO from her AdvisoryLibrary/2009/mar6(1)/Pages/03.aspx. sister facility in the Northeast Region, asked when the Authority would be hiring a PSL for, and have func- 2. The Pennsylvania Code, Chapter 551.21, § 1005.10, tions like this in, the Southeast Region. Licensure and general operating standards, Section I, (c), (A)., Amended October 1999, Criteria for Ambulatory Toward the conclusion of the program, the attendees Surgery [online]. [cited 2009 May 18]. Available from had the opportunity to participate in a limited open Internet: http://www.pacode.com/secure/data/028/ forum about shared issues. One PSO was from a chapter551/chap551toc.html. Page 38 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 2—June 2009 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 2—June 2009. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2009 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.