Portland, OR — On June 1, the Oregon Patient Safety Commission (OPSC) released a report summarizing the data Oregon healthcare facilities contributed to the Patient Safety Reporting Program (PSRP) in 2015. PSRP is a central location for data that informs patient safety and improvement efforts in Oregon. In 2015, Oregon healthcare facilities contributed more information than ever about adverse events, why they occur, and strategies for making care safer.
The 2015 Annual Summary provides a statewide, aggregate picture of information reported to PSRP, which is comprised of contributions from four different healthcare segments: ambulatory surgery centers, hospitals, nursing facilities, and community pharmacies. Although the contributing healthcare segments differ, many of the patient safety challenges and improvement strategies identified in PSRP reports translate across healthcare segments. Highlights from the 2015 Annual Summary include:
- Healthcare facilities contributed 704 reports to PSRP in 2015—the largest number submitted in a single year since the reporting program began
- The most frequently reported adverse events were falls, medication or other substance events, surgical or other invasive procedure events, and care delays—collectively, these events make up 63% of the 2015 events reported to PSRP
- As expected from the program’s emphasis on serious adverse events, nearly half of the 2015 reports (48%) were about a serious harm or death event
- From 2012 to 2015, contributions of acceptable quality reports increased from 44% to 65%—quality content provides a comprehensive picture of one facility’s experience so the information can be used to help others learn and improve
- Facilities can continue to improve the quality of their reports by better identifying the core reasons why adverse events occur (“root causes”) and developing action plans to prevent similar events, making care safer in the long term
“We commend Oregon healthcare facilities for sharing valuable patient safety information,” said Gwen Cox, executive director of the Oregon Patient Safety Commission. “We are pleased by continued increases in the quantity and quality of reports being submitted. We interpret these gains not as a sign that more adverse events are occurring in Oregon; but rather, as a sign that healthcare facilities are increasing their dedication to learning from adverse events to improve patient safety.” OPSC uses what is learned from the data to inform patient safety work across Oregon.
The 2015 Annual Summary: Patient Safety Reporting Program is available at: http://oregonpatientsafety.org/reporting-programs/annual-summaries/
About the Oregon Patient Safety Commission
OPSC is a semi-independent state agency charged by the Oregon Legislature with reducing the risk of serious adverse events occurring in Oregon’s healthcare system and encouraging a culture of patient safety. OPSC operates the Patient Safety Reporting Program, offers Oregon healthcare organizations a variety of opportunities to participate in infection prevention trainings and collaboratives, and is the administrative entity for Early Discussion and Resolution—Oregon’s voluntary process for open conversation between healthcare providers and patients, if serious physical injury or death occurs during healthcare.
