Facilities, Not Just Patients Report Adverse Events to Patient Safety Commission

Patients and their families report two-thirds of the adverse events in Oregon’s first-of-its-kind, statewide voluntary program to give healthcare providers and patients a chance to have a confidential conversation and can have a mediator present. Surprisingly, facilities are filing one-third of all the notices to the Patient Safety Commission.

“Transparency can be scary in these situations,” said Bethany Walmsley, executive director of the Oregon Patient Safety Commission. “But some providers recognize it’s the right thing to do for all involved. Providers, patients and families all benefit so improvement can happen. If we don’t do this, we’ll never get better.”

Walmsley and her team reported to their board about a new website and other outreach for early discussion and resolution of adverse events. The program offers patients and healthcare facilities a way to have an open and confidential conversation when a serious injury or a death occurs.

This year, the commission started a standardized notice system to foster transparent, timely resolution of adverse incidents.  As of April 14, a third of the notices had been filed by facilities and two-thirds by patients, according to the program’s director Melissa Parkerton.

To spread the word, Parkerton initiated an ambitious outreach program with presentations, webinars and exhibits to medical, dental, and pharmacy associations, and is also speaking to liability insurers and the legal community.

“It’s nice to be invited,” Parkerton said. “It’s a sign of interest.”

Insurers also provide training and support, and Parkerton said the commission needs to find the “gap where we can add value and not duplicate what’s happening.”  Currently most consultations occur by phone about specific incidents. Parkerton said 35 percent of the calls come from providers or facilities and average 12 minutes in length compared with 47 percent from patients averaging 25 minutes. The commission’s full report on the early discussion program is expected this fall  

Mary Post, director of infection prevention for the commission, also old the board about “one of my favorite projects of my career”—the Oregon Stop UTI Initiative, aimed at reducing unnecessary use of antibiotics in long-term care facilities.

A nursing home survey showed that handoffs, communication openness, non-punitive response to mistakes and staffing led the list of safety concerns. Respondents want more training and open communication when mistakes happen so they can be fixed quickly.

Post told the board about a staff lounge where staffers could fill out note cards with their patient safety concerns. “It’s not direct communications but it’s a start,” Post said. “The No. 1 takeaway is to keep messaging simple, focused and easy to do.”


Jan can be reached at [email protected] 

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