Learn more about Patient Safety meetings

Presenter:

• Shanna Jaggers- MPA, LSS
  • Patient Safety Surveillance and Improvement Program Coordinator
  • Office of Research and Evaluation
  • Utah Department of Health and Human Services

• Presentation
• The presentation included:
  • What is patient safety?
  • How to access REDCap.
  • How to complete a patient safety report?
  • What is a patient safety event?

The meeting was open to all patient safety REDCap users.

Presenter:

• Presenter:

  • Shanna Jaggers- MPA, LSS
    • Patient Safety Surveillance and Improvement Program Coordinator
    • Office of Research and Evaluation
    • Utah Department of Health and Human Services
  • Presentation
  • The presentation included:
    • Annual Report Review

  The meeting was open to all patient safety REDCap users.

Presenters:

• Bonnie DiPietro- RN, MS, NEA-BC, FACHE, Vice President of Operations at the Maryland Patient Safety Center.

• Presentation Slidedeck opens in a new tab - Downloadable Slides

• For the August 2022 patient safety workgroup meeting, we were joined by Vice President of Operations at the Maryland Patient Safety Center, Bonnie DiPietro. 

  Bonnie gave an overview of the mission and goals of the Maryland Patient Safety Authority as well as how they partner with stakeholders in their region. She provided insight about their reporting infrastructure and the policies in place for healthcare facilities to report adverse patient safety events. 

  The meeting was attended by representatives of various organizations including Intermountain Healthcare, University of Utah Healthcare, Comagine Health, Select Health, Milford Valley Memorial Hospital, Utah Department of Health, and many others.

Presenters:

• Michelle Bell - RN, BSN, FISMP, CPPS, Director of Outreach & Education at the Pennsylvania Patient Safety Authority

• Presentation Slidedeck opens in a new tab - Downloadable Slides

• For the June 2022 patient safety workgroup meeting, we were joined by director of the Pennsylvania Patient Safety Authority, Michelle Bell. 

  Michelle gave an overview of the mission and goals of the Pennsylvania Patient Safety Authority as well as how they partner with stakeholders in their region. She provided insight about their reporting infrastructure and the policies in place for healthcare facilities to report adverse patient safety events. 

  The meeting was attended by representatives of various organizations including Intermountain Healthcare, University of Utah Healthcare, Comagine Health, Select Health, Milford Valley Memorial Hospital, Utah Department of Health, and many others.

Presenters:

• Riley Voss, MPH, CPH - Public Health Associate Program, Center for State, Tribal, Local, and Territorial Support, Centers for Disease Control and Prevention on assignment at the Utah Department of Health
• Sri Bose, PhD – Patient Safety Surveillance & Improvement Program Coordinator and Economic Analyst for the Center for Health Data & Informatics

• Presentation Slidedeck opens in a new tab - Downloadable Slides

• Riley Voss, MPH, Public Health Associate at the Center for State, Tribal, Local, and Territorial Support within the Centers for Disease Control and Prevention on assignment at the Utah Department of Health delivered a presentation regarding data reported to the Patient Safety Surveillance and Improvement Program (PSSIP) from healthcare facilities throughout the state. The PSSIP is required by administrative rule to report to the workgroup meeting annually. In this meeting, attendees learned about the leading patient safety events, factors that contributed to the events, the actions facilities took to address and prevent future patient safety events, and the outcome of the patients involved in reported patient safety events. The PSSIP began collecting more in-depth information regarding the demographics of patients involved in patient safety events from reporting facilities in the fall of 2021 and results from these reports were also shared with the patient safety workgroup. 

  Prior to the presentation, Sri Bose, Patient Safety Surveillance & Improvement Program Coordinator and Economic Analyst for the Center for Health Data & Informatics, facilitated a conversation regarding the results of a survey that was sent to the workgroup, which sought feedback about the language in rule and reporting requirements for maternal and child health adverse events as well as the different levels of harm for adverse events. 

  The meeting was attended by representatives of various organizations, which included but were not limited to: Coral Desert Surgery Center, the University of Utah Health, Intermountain Healthcare, Comagine Health, Encompass Health, the Utah Medical Education Council, and the Utah Department of Health.

Presenters:

• Oscar Zamudio – MPH Candidate, University of Utah & OHCS Intern
• Sri Bose, PhD – Patient Safety Surveillance & Improvement Program Coordinator and Economic Analyst for the Center for Health Data & Informatics

• Presentation Slidedeck opens in a new tab - Downloadable Slides

• For the February 2022 Patient Safety Workgroup Meeting, Oscar Zamudio, OHCS intern and MPH candidate at the University of Utah, delivered a presentation regarding medication reconciliation. This topic was selected due to interest and feedback received from the Patient Safety Workgroup in prior meetings. In this meeting, attendees learned about the Institute for Healthcare Improvement’s definition of medication reconciliation, the number of patients impacted by errors due to medication reconciliation at a national level, and a number of factors that contribute to medication reconciliation related medical errors. Moreover, the group learned about what has worked well across several entities to improve patient safety by modifying practices as it relates to medication reconciliation. 

  Prior to the presentation, Sri Bose, Patient Safety Surveillance & Improvement Program Coordinator and Economic Analyst for the Center for Health Data & Informatics, facilitated a conversation regarding the reportability of maternal related adverse patient safety events, and possible ideas on updating the State administrative rule, in an effort to ensure alignment in reporting.  

   The meeting was attended by representatives of various organizations including but not limited to: Central Valley Medical Center, Coral Desert Surgery Center, the University of Utah Health, Intermountain Healthcare, Comagine Health and the Utah Department of Health.

Presenters:

• Iona Thraen, PhD, MSW - Director of Patient Safety
• Raelynn Frederickson, MSN, RN, CPPS - Sr. Patient Safety Clinical Consultant
• Helen Smith, PT, DPT, MS-HSA, CPPS - Patient Safety Clinical Consultant
• Deborah Sax, MS, RN, CPPS - Senior Patient Safety Clinical Consultant

• Presentation Slidedeck opens in a new tab - Downloadable Slides

• Recording available upon request

• For the December 2021 Patient Safety Workgroup Meeting, we were joined by Iona Thraen, Raelynn Frederickson, Helen Smith and Deborah Sax from the University of Utah Healthcare Department of Patient Safety.

  During the meeting, the team described the various components of the patient safety program at the U, including their staffing structure, the patient safety reporting system used, and the approximate number of events reported each year. The team also guided the patient safety workgroup through the life cycle of a patient safety report, safety event classification definitions, and how the team interprets and applies the administrative rules set forth by the Utah Department of Health.

  The meeting was attended by representatives of various organizations including Intermountain Healthcare, Shriners Hospital, University of Utah Health, Beaver Valley Hospital, Cascades Skilled Nursing, Comagine Health, Utah Department of Health, and Salt Lake Regional Medical Center.

• Shane Lewis, MD, FACS - System Medical Director of Safety, Quality & Clinical Risk
• Dani Howard, MBA - Clinical Operations Manager for Patient Safety & Clinical Risk

Presentation Slidedeck opens in a new tab - Downloadable Slides

For the October 2021 Patient Safety Workgroup Meeting, we were joined by Dr. Shane Lewis and Dani Howard from the Intermountain Healthcare Office of Patient Experience.

During the meeting, the team discussed the Office's approach to safety, quality, experience & clinical risk; the structure of the office, and the workgroups under the office's purview. Additionally, Dr. Lewis and Dani discussed the set of high reliability tools used by the team at Intermountain Healthcare, the process of handling patient safety events, as well as the emphasis on and value of apology and connection.

The meeting was attended by representatives of various organizations including Intermountain Healthcare, University of Utah Healthcare, Comagine Health, Milford Valley Memorial Hospital, Utah Department of Health, and many others.

Presenter:

• Carl Letamendi, Office of Health Care Statistics, Utah Department of Health 
• Max Sidesinger, Office of Health Care Statistics, Utah Department of Health

• Presentation Slidedeck opens in a new tab - Downloadable Slides

• Recording available upon request

• For the August 2021 Patient Safety Workgroup Meeting, we presented the Mission, Vision, and Objectives of the Patient Safety Workgroup. The group approved the Mission, Vision, and Objectives document after hearing comments and suggestions from participants of the meeting. 

  Max Sidesinger, a now former Patient Safety Intern at the Office of Health Care Statistics, also gave a presentation on Patient Safety Initiatives outside of the state of Utah. The purpose of Max’s presentation was to learn about the adverse event reporting systems of other states and to explain why comparing adverse event reporting systems across states is difficult. Max also shared his examination of different tools used to report adverse events including ones from the National Academy For State Health Policy, the Agency for Healthcare Research and Quality (AHRQ), and the Agency for Healthcare Research and Quality (AHRQ). 

  The meeting was attended by representatives and former representatives of various organizations including Intermountain Healthcare, University of Utah Healthcare, Milford Memorial Hospital, Shriners Hospital for Children, and Coral Desert Surgery Center. 

Presenter:

• Dr. Brent James, Clinical Professor at the Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University School of Medicine

• Presentation Slidedeck opens in a new tab - Downloadable Slides

• Recording opens in a new tab

• For the June 2021 Patient Safety Workgroup Meeting, we had the pleasure of being joined by Dr. Brent James. Dr. James is known internationally for his work in clinical quality improvement, patient safety, and the infrastructure that underlies successful improvement efforts, such as culture change, data systems, payment methods, and management roles. He is a member of the National Academy of Medicine (formerly known as the Institute of Medicine), and participated in that organization’s seminal works on quality and patient safety. Dr. James is a Clinical Professor at the Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University School of Medicine, and he holds adjunct faculty appointments at the Harvard School of Public Health (Health Policy and Management), University of Utah David Eccles School of Business and the University of Utah School of Medicine (Family Medicine; Biomedical Informatics). During the presentation, Dr. James walked us through a thought-provoking presentation regarding patient safety and systems science, detecting care-associated injuries, human interaction with complex systems, and design ideas for safety systems. The presentation also sparked thoughts surrounding reframing handling of reports, and included prior research in medical error and adverse events.

  The meeting was attended by over 60 representatives from various organizations, including: the Utah Department of Health, the Utah Insurance Department, the Kem Gardner,  Comagine Health, Gunnison Valley Hospital, Ashely Regional Medical Center, Intermountain Healthcare, University of Utah Hospitals and Clinics (UHealth), Coral Desert Surgery Center in St. George, Regence Blue Cross Blue Shield, Molina Healthcare, the Salt Lake County Health Department, HCA Healthcare, Blue Mountain Hospital, the National Association of Health Data Organizations, and Humana.

Presenter:

• Deepthi Rajeev, Comagine Health
• Sara Phillips, Comagine Health

• Presentation Slidedeck opens in a new tab - Downloadable Slides
• ED Guide Checklist opens in a new tab
• ED Levels Resource Guide opens in a new tab

• Recording opens in a new tab

• For the April 2021 Patient Safety Workgroup Meeting, guest speakers Deepthi Rajeev and Sara Phillips from Comagine Health discussed current quality initiatives. The presenters kicked off the meeting by discussing Comagine Health's background, geographic reach and services. Their clients include CMS, AHRQ, the CDC, NIH/NIDA and state and county health departments, among others. Some of the major highlights of this presentation include quality improvement innovation initiatives, infection prevention initiatives (including Utah Infection Prevention Collaborative), levels of care for treating overdose and opioid use disorder in emergency departments, and their hospital quality improvement project.

  Attendees from across the state represented various organizations, including: Central Valley Medical Center, Ashley Regional Medical Center and University of Utah Health.

Presenters:

• Carl Letamendi,  Office of Health Care Statistics , Utah Department of Health
• Srimoyee Bose, Center for Health Data and Informatics, Utah Department of Health

• Analysis of patient safety events reported in Utah - Downloadable Report

• Recording

• For the first Patient Safety Workgroup meeting hosted in 2021, the Office of Health Care Statistics held a meeting to present an analysis of patient safety events reported in Utah. The report started by discussing patient safety events reported over the last decade (2010-2020), identification of the top three occurrence categories (surgical, care management and patient protection), contributing factors and actions taken. Then, similar results were presented for each month for just calendar year 2020. Some of the major takeaways were that education is the most reported corrective action taken, falls are the most commonly reported care management event, and patient death is the most reported patient outcome.

  Attendees from across the state represented various organizations, including: Gunnison Valley Hospital, Kane County Hospital, University of Utah, Ashley Regional Medical Center, Jordan Valley Medical Center, HCA Healthcare, Coral Desert Surgery Center and Comagine Health.

Presenter:

• Robin Betts, Vice President, Quality, Clinical Effectiveness & Regulatory Services
  Kaiser Foundation Hospitals and Health Plan, Kaiser Permanente Northern California

• High Reliability in Action opens in a new tab - Downloadable Slides

• Recording opens in a new tab

• For the last Patient Safety Workgroup meeting of the year, we had the pleasure of being joined by Robin Betts. Robin Betts is a leader in clinical innovation and the implementation of safety improvement initiatives and has dedicated her professional life to patient safety, quality, and high reliability systems to elevate safety and quality in health care. As Vice President for Quality, Clinical Effectiveness & Regulatory Services for Kaiser Permanente Northern California, Robin helps further advance Kaiser Permanente's nation-leading excellence in quality and patient safety, mental health services and oversees health plan and hospital regulatory functions, including compliance, licensing, and member grievances. In 2013, the Patient Safety Movement Foundation awarded Robin with its Humanitarian Award that recognizes leaders from around the world who have made significant progress in saving lives from preventable medical harm.
  
  During the presentation, titled High Reliability in Action, Robin provided an overview of Kaiser Permanente's model, which encompasses its health plan, its medical groups and hospitals. In addition to providing a snapshot of Kaiser Permanente's work in California, she also discussed Kaiser's recognition in the country when it comes to quality performance, the operational excellence operating model, high reliable care in times of COVID-19, the sustainability framework, and discussed the safety priority index and how it's calculated.
  
  Patient safety advocates, clinical risk managers and coordinators were among those who attended the presentation. The organizations represented include, but were not limited to: Intermountain Healthcare, University of Utah, Ashley Regional Medical Center, Southwest Utah, the National Committee of Vital Health and Statistics, Utah Citizens Counsel, Utah Harm Reduction Coalition, and HCA Healthcare.

Presenter:

• Dr. Donna Prosser, Chief Clinical Officer
  Patient Safety Movement Foundation

• Creating a Foundation for Safe and Reliable Care opens in a new tab - Downloadable Slides

• Recording opens in a new tab

• For our October meeting, the Utah Patient Safety Workgroup was joined by Dr. Donna Prosser. Dr. Prosser has been in the healthcare industry for more than 30 years and is the Chief Clinical Officer at the Patient Safety Movement Foundation. She spent the first fifteen years of her career at the bedside and transitioned into administration after a personal experience helped her to understand just how fragmented and unsafe patient care can be. This experience ignited a passion to improve healthcare quality and safety in her that continues to burn to this day. Prior to joining the Patient Safety Movement Foundation, Dr. Prosser worked as a healthcare consultant, helping organizations across the United States to improve quality and safety, increase patient engagement, and reduce clinician burnout. Before beginning her consulting career, she was responsible for clinical practice improvement across Martin Health System, while also functioning as Site Administrator and Chief Nursing Officer for the system's largest hospital. She previously held administrative, education, and clinical roles at both Carteret Health Care and the Washington Hospital Center.

  During her presentation, titled Creating a Foundation for Safe and Reliable Care, Dr. Prosser shed light on the estimated economic impact of medical errors, the current state of patient safety, and shared an array of tips and resources on how hospital systems across the state can work to keep Utah's patients safe. A recording of her of the presentation is available as well.

Presenter:

• Office of Health Care Statistics

• Recording opens in a new tab

• August Patient Safety Workgroup presentation opens in a new tab - Downloadable Slides

• For this the August Patient Safety Workgroup presentation, the Office of Health Care Statistics shared details around the Office's work, which includes managing the Utah Patient Safety Surveillance & Improvement Program, the datasets under its purview, and recapped the administrative rules surrounding patient safety in the state. After describing the results and major takeaways of a Hospital Safety Report and the results of an independent survey of hospital and health system leaders, presenters described the frequency of patient safety events in Utah from 2015 to date. Observations included, but were not limited to: number of patient safety events by occurrence category (surgical events, care management events, patient protection events, etc.), reported contributing factors to safety events (communication, human factors, process breakdowns, etc.), and reported actions taken to mitigate and correct the error (education, process redesign, policy & procedures, etc.).