Clinical nurse specialist Dana Moore trains nurse Peter Herrick-Stare to use Patient Safety Net, a streamlined system for reporting adverse events that clears the way for safer patient care.

In the past, reporting adverse events such as equipment failure and patient falls involved cumbersome procedures and countless forms, scattered according to department and event type. Now Patient Safety Net, or PSN, a new online system set to roll out across Hopkins Hospital this summer, offers the ease of one-stop reporting plus unprecedented data collection capabilities.

But along with the added convenience will come an increase in the number of reported errors—at least initially. University HealthSystem Consortium, the company that developed PSN, says the number of reports could spike as much as fivefold within the first six months of using the system. To Lori Paine, the hospital’s patient safety coordinator, that’s actually a step forward. “If we want to know what’s wrong with the system, we have to first know where it’s failing,” she says. “That requires us to have a window into the operation through people telling us when errors happen.”

PSN is the latest of several initiatives that push for a more transparent culture of safety at Hopkins. It will make communicating safety concerns easy—no more complicated, Paine suggests, than buying something online. Errors, as well as service complaints, such as missed meals or lost property, can be logged into PSN electronically from any public workstation, a process that automatically e-mails a report directly to the people who can address the problem.

Say a heart monitor fails on Unit X. The nurse would simply sign onto PSN, choose the event type and answer the questions when prompted. Within seconds, Unit X’s nurse manager would receive a report in her e-mail inbox, and simultaneously, a clinical engineering manager would receive the same report. If a patient or visitor were harmed by the event, an e-mail would also go to the physician and to Unit X’s performance improvement representative. All report recipients would then have a set amount of time to respond using PSN, and if they don’t, they’ll be nudged by the system’s administrator—a new position for which Paine is recruiting.

Nurses and pharmacists, who will potentially log as many as 80 percent of incidents, are among the first to complete training. Dana Moore, a clinical nurse specialist on the medical intensive care unit who is helping Paine to coordinate the rollout, knows firsthand the difference it will make for nursing staff. “They’re often frustrated when they take the time to find the right form, fill it out and send it off, and then it sits on someone’s desk until that person has all the information and the time to act on it,” she says. “Now, these reports can be addressed more quickly.”

The tricky part will be encouraging employees to understand why using the streamlined system is so important. “People aren’t sure what the value in reporting is, because they aren’t seeing data that suggests that things get better when they speak up,” says Paine.

Nowhere is speaking up more critical than in dispensing medication. According to a 2002 Journal of the American Medical Association study of 36 medical institutions, 1 percent of doses given in error had the potential for causing serious harm, such as when an order is misinterpreted (see “Prescription for Safety” below). If that percentage were applied to Hopkins’ 13,000 daily doses, it could, in theory, translate into 130 serious errors each day—far more than what reporting currently reflects. “We want to make sure the number of reported errors is as close as possible to the number of actual events so we can fix what’s broken,” says Bob Feroli, assistant director for pharmacy patient safety.

Ultimately, all error reports enter a master database supported by PSN, rendering their data ripe for use in mapping trends across departments and event types, and, for the first time, in benchmarking Hopkins against other institutions. Nearly two dozen academic medical centers across the country—including Stanford and the University of Wisconsin—are already using the PSN system successfully.

But Paine stresses that PSN can only succeed at Hopkins if employees do their part in exposing the problem areas. “We’re beginning to appreciate the fact that a smaller number of reported errors isn’t necessarily better; it means that people aren’t reporting as much,” says Paine. “We need to build a culture in which people know how to report and feel comfortable doing it.”

—Lindsay Roylance

To access PSN, open the public workstation home page (www.insidehopkinsmedicine.org/jpl/) and click on “PSN–Report an Event or Service Concern.” Nurse info: www.insidehopkinsmedicine.org/nursing/wn/PSN.html.

Info: Lori Paine, lapaine@jhmi.edu; Dana Moore, dmoore2@jhmi.edu.

NOTE: Emergent events such as fire (5-4444), security alerts (5-5585) or blood exposure (5-STIX) should still be reported using the emergency phone numbers on your Hopkins On Alert badge.

Prescription for Safety Ever try to read someone’s hand-scrawled note and can’t tell if they wrote, “Meet me at 1” or “Meet me at 11”? Imagine the gravity of getting it wrong if that number represented a dosage for a patient’s medication. That’s why the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) created a list of abbreviations, acronyms and symbols that should never be used—and why Hopkins is adhering to it strictly. For example, “U” is a common abbreviation for “unit,” as in units of insulin. But what if “10 U,” hastily scribbled on a chart, looked more like “100”? It could mean life or death. Safety musts: Make orders clear and complete. (Include patient name, date and time, patient weight, allergies, drug name, dose—indicate mg/kg for pediatrics, frequency, route of administration, signature and prescriber identification number on all medication orders.) Avoid issuing verbal orders. (If you do, ask to have your order read back to verify.) Use decimal points properly: Correct Incorrect 0.5 mg .5 mg 10 mg 10.0 mg Prohibited abbreviations at Hopkins: “U” or “IU” for unit/international unit “d” for days or dose X3 for “times 3 doses/days” µg for microgram Ø for “no” or “none” MS04 or MS for morphine MgSO4 for magnesium sulfate QD for once daily QOD for every other day Report errors and/or adverse drug reactions using Patient Safety Net. (Info: www.insidehopkinsmedicine.org/icpm/PME006-abbreviations.pdf)