Making Hospitals Safer

The Patient Safety Surveillance and Improvement System

Project Summary

We all hope the hospital is a safe environment for patients. Unfortunately, there are instances when patients and staff are harmed because of system or process issues. In 2006, the Vermont Department of Health (VDH) began the Patient Safety Surveillance and Improvement System (PSSIS) with the goal of improving hospital patient safety and reducing adverse events.

The PSSIS requires that Vermont hospitals report patient and staff harm based on the National Quality Forum (NQF) Serious Reportable Event (SRE) criteria.These events are considered significant and largely preventable, and must be reported within seven days of their discovery by the hospital.

Once an event is reported, the PSSIS requires that hospitals conduct a thorough investigation of the event to determine its root cause. This detailed investigation, or Root Cause Analysis (RCA), evaluates specific factors that contributed to the event, which are then integrated into a Corrective Action Plan (CAP). The CAP must identify the specific steps needed to mitigate the root cause(s). Both the RCA and CAP are reviewed by VPQHC before being submitted to the Vermont Department of Health.

The VPQHC Patient Safety program staff also routinely visit each hospital to evaluate their patient safety processes and review the progress of their CAPs. The goal of the visits is to ensure that every item in the PSSIS Rule is not only incorporated into the hospital's policies and processes, but is integrated into daily practices.

Recommendations and Next Steps

Supporting the hospitals' patient safety systems and processes is a priority for VPQHC. In the upcoming year, VPQHC will continue reviewing SREs, RCAs and CAPs, and plans to visit six additional hospitals to assess their policies and processes related to patient safety. Through our work with the PSSIS, we will also promote best practice models, provide education, increase awareness, and support the collaboration between hospitals.