1. State of Utah Patient Safety Initiatives Iona M. Thraen, ACSW

2. Presentation Outline • Overview – Defining the Problem • SE reporting and analysis • ADE reporting and analysis • Patient Safety Reporting for Consumers • Intervening • ADE users group • SE users group • HAI users group • Perinatal Mortality and Morbidity Review

3. Overview – Community Coalition Utah Health Data Committee SB132 Task Force Maternal and Infant Mortality Review Committee (proposed)

4. Overview • IOM Report 1999 – To Err Is Human • State Administrative rule - October 15, 2001 • SE reporting rule • Voluntary reporting, RCA, and action plan reporting • ADE reporting using administrative data • Health Data Committee – Hospital discharge data • 3 year audit for ADE reduction program • AHRQ grant • VA/AHRQ team training • State absorption of responsibilities • Law: SB132 mandates Utah Health Data Committee to release comparative reports on patient safety, quality and charge for consumer audience • Law: HB132 Pain Medication Management and Education $150,000 for two years.

5. Overview Continued Partnership between UDOH, UHA, UMA, and Health Insight (QIO) • Patient Safety Guidance Council • SE Users Group • ADE Users Group • HAI Users Group • Perinatal Review Committee

6. Overview Continued • Statewide Philosophies • Non Punitive • Community Partnerships • User driven • Administrative guidance • Data/evidence based • Level playing field • Administrative not legislative • Accountability • Non burdensome

7. State-wide Interventions • ADE users group – • Failure Mode Effects Analysis (FMEA) • Anti-Coagulants • Insulin • SE users group – • C³ - Correct Patient, Correct Procedure, Correct Site • HAI users group – • Rules, Reporting form, WEB site

8. Patient Safety WEB Site • http://health.utah.gov/psi/ • Contact: • Iona Thraen, Patient Safety Director • HIS/UDOH • 538-6471