CENTER FOR PATIENT SAFETY
PSODATA
snapshot Data continues to pour in to the Center’s PSO database. In the four-quarter period from October 1, 2012 to September 30, 2013, the Center received nearly 3000 events including incidents, near misses, and unsafe conditions. While 95% of the events received were incidents, it is important to note that the lessons learned from analyzing patient safety events that do not reach the patient (near misses and unsafe conditions) are just as important as analyzing the information about events that did reach the patient. In the most recent four quarter period, falls were the most often reported event with medication or other substance events following closely behind. The same period’s data includes 18 deaths reported (graphic at right) and 23 severe/permanent harm. Eight of the deaths were related to a healthcare-associated infection. Of the 23 severe/permanent harm, ten were related to falls. The Center for Patient Safety strongly encourages you to report your events to a Patient Safety Organization. IMPORTANT NOTE: The deidentified data that makes up this report was obtained from the Center’s PSO database using the following criteria: 1) events were entered into the database with Initial Report Dates between October 1, 2012 and September 30, 2013 and 2) events were submitted to the PSO. REMINDER: PSO adverse event reporting cannot be used for comparison of individual organizations. The purpose of PSO adverse event reporting is to learn what events occur and why, and to use that information to prevent future occurrence and patient harm. The value is in the quantity, quality, and details! The more reports obtained by the PSO containing detailed information about errors, near misses, and unsafe conditions, the greater potential for learning, sharing ,and proactively preventing future harm, costs, and liability exposure.
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Did You Know
Interested in receiving more information about PSO services available to you? Visit our website at www.centerforpatientsafety.org
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