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.

Read more about SB 483 »

Senate Bill 483 Signed into Law

On Monday, March 18, Governor Kitzhaber signed Senate Bill 483—a landmark piece of legislation that establishes a voluntary program to give healthcare providers a structured approach to notification, discussion, and mediation of serious adverse events. SB 483 advances and promotes appropriate treatment and communication for patients and families in the aftermath of serious adverse events. The bill adds an important new role to the Commission’s work and the Commission is pleased to be a part of this landmark legislation.

Read More about SB 483 »

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.

Read the article »

Slide ORHQN

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.

View event brochure »
Register for seminar »

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.

Read the Statement »

NEW Action Alerts

Check out a new feature on our website
Informed by reports submitted to Oregon’s Patient Safety Reporting Program, Action Alerts provide up-to-date information about specific experiences and threats to patient safety in ambulatory surgery centers, hospitals, pharmacies, and nursing homes. Each alert provides recommendations for how healthcare providers can take action to identify and prevent similar events from occurring in Oregon facilities.

Slide ORH OSPA

     

Slide OHCQC OMA

     

Slide OHA OHCA

     

Slide OCHCP DHS

     

Slide OAHHS OCN

     

Slide NRN OASCA

     

Slide Acumentra-LeadingAge

     

Privacy Policy

The Oregon Patient Safety Commission has established policies to protect the security and privacy of all information we collect. We maintain strict internal policies against unauthorized disclosure or use of any client or web site user information. Any suspected attempt to breach our policies and procedures, or to engage in any type of unauthorized action involving our web systems will be regarded as potentially criminal activity, and may be reported to the appropriate authorities.

Protected Patient Safety Data

Oregon Revised Statutes (ORS) 2009, Chapter 442.819 through 442.851 specifically addresses disclosure and protection of patient safety data (the entire statute is available online here).

442.844 Patient safety data; use; disclosure.

1. Patient safety data reported to the Oregon Patient Safety Commission and information developed pursuant to the auditing and oversight described in ORS 442.837 (1) may not be disclosed to, subject to subpoena by or used by any state agency for purposes of any enforcement or regulatory action in relation to a participant.
2. Nothing in ORS 442.819 to 442.851 may be construed to limit the regulatory or enforcement authority of any state agency and, except for patient safety data, state agencies have the same authority to access participant records or other information in the same manner and to the same extent as if ORS 442.819 to 442.851 were not enacted.
3. As used in this section, “state agency” has the meaning given that term in ORS 183.750. [2003 c.686 §5] Note: See note under 442.819.

442.846 Patient safety data not admissible in civil actions.

1. Patient safety data and reports obtained by a patient safety reporting program from participants are confidential and privileged and are not admissible in evidence in any civil action, including but not limited to a judicial, administrative, arbitration or mediation proceeding. Patient safety data, patient safety activities and reports are not subject to:
   1. Civil or administrative subpoena;
   2. Discovery in connection with a civil action, including but not limited to a judicial, administrative, arbitration or mediation proceeding; or
   3. Disclosure under state public records law pursuant to ORS 442.820 (3) and, if permissible, federal public records laws.
2. The privilege established under this section does not apply to records of a patient’s medical diagnosis and treatment and to records of a participant created in the ordinary course of business.
3. Patient safety data, collected or developed for the purpose of and with the intent to communicate with or to make a disclosure or report to the patient safety reporting program, that are contained in the business records of the participant are confidential and not subject to civil or administrative subpoena or to discovery in a civil action, including but not limited to a judicial, administrative, arbitration or mediation proceeding.
4. The following persons are not subject to an action for civil damages for affirmative actions taken, acts of omission or statements made in good faith:
   1. A person serving on the Oregon Patient Safety Commission Board of Directors;
   2. A person serving on a committee established by the board;
   3. A person communicating information to the Oregon Patient Safety Reporting Program; or
   4. A person conducting a study or investigation on behalf of the program.
5. A participant or a representative of the Oregon Patient Safety Reporting Program may not be examined in any civil action, including but not limited to a judicial, administrative, arbitration or mediation proceeding, as to whether a communication of any kind, including oral and written communication, has been made or shared with another participant or with the program regarding patient safety data, patient safety activities, reports, records, memoranda, analyses, deliberative work, statements or root cause analyses, provided the communication was made with the intent of making a disclosure to or preparing a report to be submitted to the Oregon Patient Safety Commission.
6. Nothing in this section may be construed to:
   1. Limit or discourage patient safety activities of or among participants or the voluntary reporting of patient safety data by one or more participants, individually or jointly, to a patient safety reporting program;
   2. Affect other privileges that are available under federal or state laws that provide greater peer review or confidentiality protections than do the protections afforded under ORS 442.819 to 442.851;
   3. Preempt or otherwise affect mandatory reporting requirements under Oregon law or licensing or certification requirements of state or federal law; or
   4. Diminish obligations of participants to comply with state and federal laws pertaining to quality assurance, personnel management and infection control requirements.
7. Reporting or sharing of patient safety data by a participant is not a waiver of any privilege or protection established under ORS 442.819 to 442.851 or other Oregon law. [2003 c.686 §12]

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