From the Director
The Commission has published the 2012 Hospital Annual Summary, which highlights that Oregon hospitals submitted more adverse event reports to the Commission in 2012 than ever before. This increase in reports is not an indication that more adverse events are occurring, but rather, that Oregon hospitals are improving their ability to identify adverse events. Full hospital participation in the reporting program helps to preserve the unique qualities of the program and will ensure that the Commission can continue to provide information on statewide trends and meaningful feedback for hospitals as an additional resource to learn and improve.
Recommendations in the 2012 Hospital Annual Summary are centered on ways hospitals can strengthen their “culture of safety”—the shared set of values, norms, practices, policies, and personnel behaviors that encompass “the way we do things around here.” We are pleased with the participation of Oregon hospitals in the Patient Safety Reporting Program and hope that hospitals will use the report and recommendations as a tool to inform and prioritize patient safety initiatives.
Bethany Walmsley (formerly Bethany Higgins)
New Legislation: SB 483
Resolution of Adverse Events
Senate bill 483 was passed by the Oregon Legislature in 2013 as an innovative approach to medical liability reform. The bill creates a confidential, voluntary program that promotes a structured process for healthcare providers and patients to notify, discuss, and (if necessary) mediate serious adverse events as an alternative to litigation.
Dislcosure Guide Featured in Health Affairs
The Commission’s Oregon Adverse Event Disclosure Guide was featured in the February issue of Health Affairs. The GrantWatch column addresses patient engagement, patient safety, and quality of care and highlights work done by the Commission to publish a resource to help providers better understand the purpose of disclosure and to develop and improve their disclosure programs.
Antimicrobial Stewardship Practical Approaches Seminar
Ensuring the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration of therapy and route of administration is essential to achieving optimal clinical outcomes, minimizing toxicity and other adverse events, and minimizing the development of antimicrobial resistance.
The Oregon Patient Safety Commission invites hospital pharmacists, physicians, infection preventionists, and other interested inpatient staff to spend a day learning about practical approaches for antimicrobial stewardship.
NEW! Statement on Preventing Oversedation
Oversedation results when the level of the patient’s sedation is greater than the desired therapeutic level of sedation. Oversedation can be associated with significant actual or potential patient harm. The Commission has published the Statement on Preventing Harm from Oversedation as a starting point for hospitals to use in efforts to decrease patient harm associated with sedation.