Julie Louise Gerberding, MD MPH Division of Healthcare Quality Promotion

1. A Patient Safety Network: Proposal from the DHHS Patient Safety Task Force for Stakeholder Consideration Julie Louise Gerberding, MD MPH Division of Healthcare Quality Promotion National Center for Infectious Diseases Centers for Disease Control and Prevention

2. A Safety Network: Vision The safety network is a knowledge system for accumulating, exchanging and integrating relevant information and resources among private and public stakeholdersthat support local efforts to protect patients and promote healthcare safety.

3. A Safety Network: Proposed Goals • Improve safety by creating and disseminating knowledge necessary to detect and respond to current and emerging healthcare safety threats • Monitor the cause, frequency and impact of targeted safety events • Establish priorities for safety promotion programs • Disseminate lessons learned • Protect confidentiality • Reduce reporting burden and ensure local access to healthcare safety information • Monitor progress toward achieving local, state, and federal patient safety goals

4. A Safety Network: Proposed Concepts • Knowledge system for patient safety is essential • Local user relevance is essential • value-added to local and state patient safety programs • decrease reporting burden; easy to use • protect confidentiality • System integration is essential • include state / federal required reports • employ standardized methods / definitions / lexicon • build from existing data system standards (e.g. National Electronic Disease Surveillance System - NEDSS) • compatible with existing systems • Modular system is optimal • evolution and evolution over time

5. A Safety Network: Proposed Information Content • Prevention tools / lessons learned / best practices • Incident reports: targeted adverse events or near misses where “zero events” is the goal • “Never” events (e.g. “wrong limb” surgery) • Sentinel events that signal a need for immediate response and root cause analyses • Unusual events that might reflect preventable threats to patient safety and deserve investigation • Rates: “best possible rate” and continuous improvement is the goal • Benchmarks (e.g. device-associated complication rate) • Performance measures • Trendsover time

6. Web Portal (Common User Interface) Federal Agencies Shared De-Identified Data Warehouse States & Other non-federal Stakeholders Users • Users • Providers / Administrators • Hospitals • Clinics / Outpatient Care Facilities • Long Term Care Facilities • Home Care Agencies • Health Plans • Consumers • Other Stakeholders • State / Local Health Departments • Peer Review Organizations • Other Contractors • ? Accreditors Data Repositories Safety Network: Sample Architecture and Integration

7. Non-federal Data Systems not linked to network Proposed Safety Network with Expansions State and non-federal Stakeholders Federal Agencies Web Portal (Common User Interface) Users Shared De-Identified Data Warehouse

8. Scenario:Patient Safety in Dialysis Units • In conjunction with many partners and stakeholders, HCFA, FDA, CDC, and AHRQ have responsibility for promoting dialysis patient safety • All 3 types of data proposed for the Safety Network are relevant: • Prevention tools / best practices / lessons learned • Incidents: e.g. access catheter malfunction; water quality failure • Rates: e.g. access infections, hospitalizations

9. Dialysis Unit Safety Network

10. Table 3. Reported Incidents, Center 999999 Patient ID Date Access Infection Thrombosis Admission ? 463 10/02/2000 Fistula 1 - N 912 11/08/2000 Temp Cath Y 181 12/01/2000 Graft 1 - Y 112 12/06/2000 Temp Cath 1 Y 103 12/07/2000 Temp Cath 1 - N 111 12/09/2000 Temp Cath 1 1 Y 181 12/11/2000 Temp Cath 1 - Y Note: Center 999999 does not exist; data developed for illustration only

11. Dialysis Unit Safety Network

13. Dialysis Unit Safety Network

17. Dialysis Unit Safety Network

19. Web Portal (Common User Interface) Federal Agencies Shared De-Identified Data Warehouse States & Other non-federal Stakeholders Users • Users • Providers / Administrators • Hospitals • Clinics / Outpatient Care Facilities • Long Term Care Facilities • Home Care Agencies • Health Plans • Consumers • Other Stakeholders • State / Local Health Departments • Peer Review Organizations • Other Contractors • ? Accreditors Data Repositories Safety Network: Sample Architecture and Integration

20. Next Steps • Modify conceptual model of Safety Network based on input from participants at this summit • Implementation contract for network development • Stakeholders meeting to specify actual content of initial data collection modules • Fast track to pilot