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Field Label | [Text of the question that appears onscreen in the online system, if applicable. If field does not appear in onscreen, put “n/a”.] | |||||
Field Name | [Field Name or Attribute Name as it appears in the database] | |||||
Question ID | [Unique id for each question, directing to Question Master Table.] | |||||
Field Location | [Section of the form in which field is found] | |||||
Default | [Default answer value, if applicable. | |||||
Use Assumptions | [What triggers this field, if anything? Does it trigger other fields, like an “other text” field? If staff only, put “staff only.” If none or extract only, put “n/a”. ] | |||||
Required | [Is this field required for submission? | |||||
Setting | [Which reporting programs use this field] | |||||
Data Type | [Format in which data is stored in database, i.e. character, number, date/time, etc.] | |||||
Old Field Name | [Field name from pre-PSRP database] | |||||
AHRQ Mapping | [Data element to which PSRP field maps] | |||||
Answer ID | Answer Code | Answer Value | A | H | N | P |
Axxxx | xx | [Answer text as it appears on screen] |
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Description
[Brief description of what this field is collecting]
On-Screen Instructions
[Prompt text as it appears in the user interface. If none, put “n/a.” If field does not appear on-screen delete this header.]
Field Type
[Type of field, i.e. date/time, text, dropdown (single select), radio button (single select), checkbox (multiselect), true/false, yes/no, etc.]
Maximum Length: [Maximum length of response, if applicable. 
Remove this header if the field is not a text field.]
Minimum Value: [Lowest value a number field will accept. Remove this header if the field is not a number field.]
Maximum Value: [Highest value a number field will accept. Remove this header if the field is not a number field.]
...
[OPTION ONE: Very many answer options with a lot of content]
[Table of contents should be limited to the answer options.]
| Table of Contents | ||||||||||||
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...
| title | Definition |
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Each answer option gets an anchor and a heading 2. It also gets an expand macro with the title “definition.” Inclusions and exclusions go in the expand macro, below which should be a link to the “top” anchor to take the user back to the responses table of content. Example page: https://oregonpsc.atlassian.net/wiki/pages/resumedraft.action?draftId=2087354595
Includes
Excludes
[If the answer option triggers additional question, add a content by label macro to display all pages that share the form_field label plus the relevant answer option label, possibly plus the relevant segment label, depending on the situation. Macro should have title “Related Content.”]
| Filter by label (Content by label) | ||||||||||
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[If the answer option is associated with an “faq” item, add a content by label macro to display all pages that share the faq label plus the relevant answer option label, possibly plus the relevant segment label, depending on the situation. Macro should have title “Additional Support.”]
| Filter by label (Content by label) | ||||||||||
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[OPTION TWO: several answer options with limited content]
...
[Each answer option gets an anchor and a heading 2. It does not get an expand macro. The definition is unlabeled and goes here, where this text is. Inclusions and exclusions go below it. There is no “top” anchor or “return to top.” Example page: Anesthesia event type ]
Includes
Excludes
[In this version, there is one “Related Content” content by label macro and it goes under “additional guidance, below.]
[OPTION THREE: a very large table]
[If there is an appendix with answer options and definitions, that content goes in the table. Example page: Event Type (Hospitals).]
...
[Item]
...
Definition
...
[Item name in bold]
...
[Description of the item.]
INCLUDES: [inclusions; separate inclusions with semicolons]
EXCLUDES: [exclusions (choose “appropriate answer option” instead); separate exclusions with semicolons (and always tell the user what to do instead)]
[Any “related content” or “additional support” content by label macros would go in the table cell below the inclusions and exclusions. BUT it feels maybe not easy to see or understand what it is?]
| Filter by label (Content by label) | ||||||||||
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| Filter by label (Content by label) | ||||||||||
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...
[Item name in bold]
...
[Description of the item.]
INCLUDES: [inclusions; separate inclusions with semicolons]
EXCLUDES: [exclusions (choose “appropriate answer option” instead); separate exclusions with semicolons (and always tell the user what to do instead)]
[Alternatively, the “related content” or “additional support” could be manually entered in an info panel macro. Easier to see that it’s something different, BUT a lot more manual updating work. ]
| Info |
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Additional Support |
[OPTION FOUR: a very short list]
[Just list the available answer options without the answerID and answerCode. Example page: Was a briefing conducted prior to the induction of anesthesia?]
Answer option 1
Answer option 2
Answer option 3
Additional Guidance
...
[In Option 2, this is where one would put a “related content” content by label macro.]
| Info |
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Additional Support |
History
...
Start Date
...
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Description
Determination of whether or not the event reached the patient.
On-Screen Instructions
ASC, Hospital, Nursing Facility: An error of omission does reach the patient.
Pharmacy: Includes medications that make it into the patient’s possession. An error of omission does reach the patient.
Field Type
| Include Page | ||||
|---|---|---|---|---|
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Responses
Yes
No
Guide for Use
If you chose more than one event type, please select the highest applicable level of harm.
Additional Support
What is a Close Call?
The Oregon Patient Safety Commission (OPSC) defines a “close call” or “near miss” as a situation that has the potential to cause an adverse event, or a situation that causes an adverse event but fails to reach the patient because of chance or because it is intercepted. Close calls include cases where there was the potential for an adverse event but no actual adverse event occurred (harm category A) or where the adverse event did not reach the patient (harm category B). OPSC encourages organizations to investigate close calls because they give facilities an opportunity to solve identified problems before a single patient has to experience an adverse event.
If an event reaches the patient but does not cause harm (harm category C), OPSC no longer considers the event a close call. For example, a patient with a documented penicillin allergy does not have an allergic reaction when given a single dose of penicillin; this event would not be included in OPSC’s definition of close call.
In the interest of promoting learning, OPSC encourages reporting of close calls (harm categories A and B) and no harm events (harm categories C and D) because such events have the potential to harm a patient and, depending on the situation and patient factors, such harm could be severe. OPSC encourages participants to focus on the occurrence of an adverse event instead of the resulting harm. Focusing on the harm, rather than the system, often detracts from the real goal—preventing future recurrence and, therefore, future harm for all patients.
When does an event reach the patient?
The Patient Safety Reporting Program (PSRP) categorizes patient harm from adverse events using an adaptation of the widely-adopted Medication Error Index from the National Coordinating Council for Medication Error Reporting and Prevention. Categorization enables PSRP data analysis to identify trends in how and why adverse events occur.
The following examples from each harm category demonstrate how this categorization is applied and when an event reaches a patient.
Harm Category | Examples |
|---|---|
Did not reach patient | |
A - Unsafe condition | In passing a shelf of medications, a pharmacist notices similarity between two medication names and thinks, “Someone could be confused; we should change this.” |
B - Near miss | A pharmacist reaches for a medication but incorrectly retrieves a similarly named medication right next to it. The pharmacist notices immediately, replaces the incorrect bottle, and selects the correct one. |
Did reach patient, did not harm patient | |
C - No harm, no change in care | The patient is handed incorrect medication and says to the nurse, “These aren’t my pills.” |
D - No harm, but required extra monitoring or an intervention to preclude harm | The patient is handed a dose of incorrect medication and takes it. The nurse realizes the medication was incorrect. The patient spends extra time in the hospital to make sure there are no ill effects. |
Did reach patient, resulted in harm | |
E - Temporary harm, no significant intervention | The patient is administered incorrect medication and experiences nausea and vomiting. The patient receives extra monitoring, but their hospital stay is not extended. |
F - Temporary harm, significant intervention needed | The patient is administered incorrect medication and experiences nausea and vomiting. A rescue medication is administered. |
G - Permanent harm | The patient is administered incorrect medication and experiences a seizure. The patient suffers permanent brain damage as a result. |
H - Required an intervention necessary to sustain life | The patient is administered incorrect medication and goes into cardiac arrest. The patient receives CPR and is defibrillated. |
I - Death | The patient is administered incorrect medication which ultimately results in the patient’s death. |
Whether or not an adverse event reaches a patient can be complicated by questions of omission and care delay. In cases where it’s unclear, it’s important to ask, “Did this event impact the patient’s course of care?”
For example, in the scenario for harm category C (above), if the nurse noticed the medication was incorrect before handing it to the patient and was able to immediately hand the patient the correct medication, then the event didn’t reach the patient (harm category B). However, if getting the correct medication and giving it to the patient caused an administration delay, then the event reached the patient. Although the patient never received the incorrect medication, the event “reached the patient” because the patient’s course of care was impacted.
History
Start Date | 2012 |
|---|---|
End Date | n/a |
Change History | n/a |
Field Name | algorithm_reachpt |