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Risk and Safety Management:
A Case Study
Stacy Norris, BSN, RN
Midas+ Infection and Risk Product Manager
Amanda DeGraeve
Midas+ Care Management Product Manager
Objectives
• Discuss applicable standards and regulations for
safety reporting of events
• Share a sample Risk Event and its life cycle
• Demonstrate how technology supports Risk Event
management
Basic Principles of Risk Event
Management
Basic Principles of Risk Event
Management
Risk Event Notification and
Response Process
Risk event occursUnit Manager is
notified
Electronic forms is completed for the
event
Unit Manager alerted via email
that an incident has occurred and needs
attention
Unit Manager begins investigating
the event
Unit Manager enters findings into the secure shared
database
Review is completed and routed to Risk Management
Risk Manager reviews information received and makes final level of harm and significance
determination for event
Further investigation
needed?Yes No
If additional managers need to
be included in investigation and makes additional
referrals as appropriate
Sentinel Event / Immediate jeopardy?
Based on new information, Risk Manager
deems incident a Sentinel Even
or needing Quality Review
for potential RCA or formal Case Review
No Yes
Event classified and closed by Risk
Manager
Qualifying events will be
reported through PSO
Event reporting process
Once all review is complete by Risk and Quality Management, available data should
be aggregated, reviewed and
appropriate actions are to be
implemented for identified
opportunities for improvement
Data aggregation that has occurred
will be used in reporting by Risk Management and
Safety Services
ACKNOWLEDGE ACT
ANALYZE
AGGREGATEACT ANALYZE
Affordable Care Act
• “We proposed to require, under new paragraph (a)(2)(i)(B), that for
plan years beginning on or after January 1, 2017 a QHP issuer that
contracts with a hospital with greater than 50 beds must ensure that
the hospital implements a comprehensive person-centered discharge
program to improve care coordination and health care quality for each
patient. We noted that use of a data-driven approach, analytic
feedback, and shared learning to advance patient safety, such as
working with a Patient Safety Organization (PSO), are essential to
implementing meaningful interventions to improve patient health care
quality.”
– Final Rule posted on March 8, 2016:
https://www.federalregister.gov/articles/2016/03/08/2016-
04439/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2017#h-8
Where Does the Data Go?
• Patient Safety
Organization (PSO)
• Patient Safety
Organization Privacy
Protection Center
(PSOPPC)
• Network of Patient
Safety Databases (NPSD)
– No data transmitted from
PSOPPC due to data integrity
issues
Case Study: Risk Event
Eighty-six-year-old male patient, Dan Arcos, was admitted to
Midas Health with sepsis. He was assessed to be a fall risk
during the admission process.
No signage was placed on his door alerting staff to the fall
frequent check protocol and no bed alarm was implemented.
On his third day of admission, he fell while attempting to walk
unassisted to the bathroom. The nurse found him on the floor
and assessed him to have a right elbow skin tear and
hematoma. The physician was notified. The nurse submitted
the event via the Remote Data Entry process to the Risk
Management Department.
Risk Event Notification and
Response Process
Risk event occursUnit Manager is
notified
Electronic forms is completed for the
event
Unit Manager alerted via email
that an incident has occurred and needs
attention
Unit Manager begins investigating
the event
Unit Manager enters findings into the secure shared
database
Review is completed and routed to Risk Management
Risk Manager reviews information received and makes final level of harm and significance
determination for event
Further investigation
needed?Yes No
If additional managers need to
be included in investigation and makes additional
referrals as appropriate
Sentinel Event / Immediate jeopardy?
Based on new information, Risk Manager
deems incident a Sentinel Even
or needing Quality Review
for potential RCA or formal Case Review
No Yes
Event classified and closed by Risk
Manager
Qualifying events will be
reported through PSO
Event reporting process
Once all review is complete by Risk and Quality Management, available data should
be aggregated, reviewed and
appropriate actions are to be
implemented for identified
opportunities for improvement
Data aggregation that has occurred
will be used in reporting by Risk Management and
Safety Services
ACKNOWLEDGE ACT
ANALYZE
AGGREGATEACT ANALYZE
Midas+ Care Management
Suggested Data Flow
Addition of the Risk Event Episode
Mapping User-defined Terms to
AHRQ Common Format Terms
Creation of the PSO Event via
Virtual Worklist Target
PSO Event
SmarTrack Reporting
ReporTrack Documents
Midas+ Juvo
Common Formats v2.0
• Public comment closed on May 9, 2016
• Target dates, subject to change:
– Technical specifications – January 2017
– Submission of events to PSOPPC using 2.0 –
August 2017
• Versions 1.2 and 2.0 will be supported
Noteworthy changes in v2.0
• Two tiers
– National and Local
• Generic forms (HERF, PIR, SIR) combined
• Local only:
– VTE, Blood and Device
• Surgery and Anesthesia separated into two forms
• HAI removed – was duplicative with NHSN
reporting
Resources
• AHRQ website:
http://www.pso.ahrq.gov
• PSO Privacy Protection Center:
https://www.psoppc.org
• Midas+ Clients Only website:
https://www.midasplus.com
Thank you for attending.
Any questions?
Stacy Norris, BSN, RN
Midas+ Infection and Risk Product Manager
Amanda DeGraeve
Midas+ Care Management Product Manager
