THE “NEW” PENN MEDICINE SAFETY NETHOUSESTAFF TRAINING – for the people who can tell us about the problems we need to solve

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What is the Penn Medicine Safety Net? A software program that allows everyone at Penn Medicine to

report problems that arise during patient care.

What’s “new” about it? Updated interface Shorter forms More ways to get feedback Easier to access (desktop icon)

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Yes – EVERYONE. Residents, nurses, advanced practitioners, faculty, pharmacists, transporters, housekeepers, EVERYONE.

Wait a minute…. EVERYONE at

Penn Medicine? You want ME to

report stuff?

1,420:Number of times housestaff

saw something and said

something last year.

Penn Medicine Safety Net

Did you?

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Safety Net Helps Find and Fix the

Holes in our System!

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Report any problems with patient care… things that could harm or did harm a patient.

It isn’t about “reporting people.” Some examples?

There was an important addendum to a CT scan, but the primary team never received a phone call

There was a complication during a procedure. We almost marked the wrong leg for surgery, but

we caught it in time and prevented harm. A patient received a dose of insulin intended for

her roommate, but fortunately no harm occurred.

What do I report? Do I report this

guy? I don’t want to “rat him out”….

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So how do I report something?

Click theSafety Net button on the Penn Intranet or

the new desktop icon

Penn Safety Net

Choose to log in as yourself using your regular email log-on

or anonymously. It is fine to report anonymously – just know

that you will not be able to receive follow-ups

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Complications of Tests /Treatments / Procedures

Errors related to Tests /Treatments / Procedures

Employee / Affiliate / Visitor Safety

Equipment / Supplies /Device Problems

Falls

Healthcare IT Problems

Medication Errors

Other / Miscellaneous

Professionalism Problems

Skin Integrity Problems

Transfusion Problems

These 2 are commonly confused…..see next slide

If you are not sure…choose “Other”

Safety Net has Different “Event Types”

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Select the form you think is best

You can type in a word to search for the best choice if you aren’t sure which form to pick for your report.

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Wait a minute….What’s the difference between

Errors related to Tests / Treatments / Procedures

Complications of Tests / Treatments / Procedures?

Did something happen (or nearly happen) because we made a mistake? Call it an “Error”.• The wrong medication was ordered or someone forgot to hand-off an

important clinical detail Did something happen that we didn’t necessarily cause,

but we didn’t want it to happen? Call it a “Complication”.• A patient aspirated and was transferred to ICU or had an MI in the OR.

and

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The naming system is the same one used by the Pennsylvania Patient Safety Authority.

It makes our data more reliable. We use it for benchmarking our safety performance against

other hospitals in the state

Where Do All These Names & Categories Come From?

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Wow…I can’t believe he just said that to me…

Professionalism Problems• Should be reported.• Your name as the reporter will always remain anonymous. You also

have the option of not attaching your name to the report at all.• We all have bad days, but unprofessional behavior to colleagues

does not make for a healthy or safe work environment. • All safety net professionalism reports entered by housestaff will be

reviewed by GME leadership and follow-up will occur.

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Examples of Professionalism Events to Report

You call in a consult and the fellow from the consultant service yells at you or refuses to accept the consultation request.

An attending intimidates or berates you in private or in front of other colleagues.

A nurse refuses to carry out an order that you place and is unwilling to have the matter mediated by a supervisor or another party.

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Tell us what happened.  JUST THE FACTS.  KEEP IT SHORT.  Don’t blame people or say what you think should or shouldn’t have happened.  You will get a call if more information is needed.

Choose the Harm Score that best matches your report. The definitions are right on the form.

Describe the Event Factually, Don’t Editorialize or State Opinions

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What is a “Harm Score”?...Sounds Scary!

If you aren’t sure, don’t agonize over it…just give it your best guess! If the reviewer of the event wishes to change the score, they can.

“Harm Scores” allow us to categorize each event and track our safety performance over time. We understand that these are new terms and sometimes you might not be sure which category to choose…..

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Now, tell us who YOU are & your department

Listing your role and department helps us provide you and your residency program leaders with feedback

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Did the event affect an inpatient, an outpatient or an employee?

If a patient was affected, the rest of the info will auto populate by entering the medical record number.

Now tell us who was affected….

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And finally, tell us where it happened:

This is really important! The department, service, and location you choose determines who receives your report. Who “owns” the problem? Who should work on solving the problem? Where did most of the problem happen or begin?

For example, let’s say you want to report a problem with a newly admitted patient. The emergency room sent the patient upstairs with the wrong medication hanging on the IV pole. The problem happened in the Emergency Room, but was discovered on the floor. The nurse manager in the Emergency Room (not on the floor) needs to look into this error…. So choose the Emergency Medicine as the Service and Department and the Emergency Room as the location.

(But don’t worry if you choose incorrectly – the nurse manager on the floor will know to send it to the Emergency Room if you pick the wrong location)

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(If you get interrupted, you can save it as incomplete by clicking on More Actions. Just remember to come back later to finish the report.)

When your form is complete, click SUBMIT

and you are done!That’s it? I’m

done?Wow - that was easy!

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Before I hit submit…I wonder who reads these?

A bunch of people!

1 - Risk Manager – a nurse with expert training in healthcare risks and patient safety

2 - Manager on the Floor/Area Where the Event Occurred – they oversee all events that occur on their unit

3 – Quality & Safety Project Manager – individual who works with the hospital to improve quality & safety

4 – Physician leaders for quality & safety in the hospital and in your department

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WAIT A MINUTE!What happened to my report? I want something done

about it!

There are 4 ways you can find out what happened to your report:

1) When you hit SUBMIT you will get an email with the name and phone number of a person you can contact with follow-up questions or concerns.

2) You can see who is managing your report in your InfoCenter list.3) When your report is closed, you will get another email with the name

and phone number of a contact person.4) Your residency program leadership will begin to receive regular

reports on events that happened in your area or were reported by you or your colleagues– ask them to share the information with you if they don’t already do so.

WAIT A MINUTE. How do I find out what happens to my report? I want something done

about it.

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And that’s Safety Net!

We know you are busy saving lives…we appreciate you taking the time to learn to use the Penn Medicine Safety Net.

Healthcare is so complex… we all have to take the time to report problems so we can improve and make our work easier, more satisfying, and safer for patients.

Thank you!

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Penn Medicine Safety Net