THE “NEW” PENN MEDICINE SAFETY NET
HOUSESTAFF TRAINING – for the people who can
tell us about the problems we need to solve
What is the Penn Medicine Safety Net?
 A software program that allows everyone at Penn Medicine to
report problems that arise during patient care.
What’s “new” about it?
 Updated interface
 Shorter forms
 More ways to get feedback
 Easier to access (desktop icon)
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Wait a minute….
EVERYONE at
Penn Medicine?
You want ME to
report stuff?
 Yes – EVERYONE. Residents,
nurses, advanced practitioners,
faculty, pharmacists, transporters,
housekeepers, EVERYONE.
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1,420:
Number of times housestaff
saw
something
and said
something
last year.
Did you?
Penn
Medicine
Safety Net
Safety Net Helps
Find and Fix the
Holes in our
System!
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What do I report?
Do I report this
guy? I don’t want
to “rat him out”….
 Report any problems with patient care…
things that could harm or did harm a patient.
 It isn’t about “reporting people.”
 Some examples?
 There was an important addendum to a CT scan,
but the primary team never received a phone call
 There was a complication during a procedure.
 We almost marked the wrong leg for surgery, but
we caught it in time and prevented harm.
 A patient received a dose of insulin intended for
her roommate, but fortunately no harm occurred.
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So how do I report something?
Click the
Safety Net button on
the Penn Intranet or
the new desktop icon
Penn
Safety Net
Choose to log in as yourself
using your regular email log-on
or anonymously. It is fine to
report anonymously – just know
that you will not be able to
receive follow-ups
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Safety Net has Different “Event Types”
Complications of Tests /
Treatments / Procedures
Medication Errors
Errors related to Tests /
Treatments / Procedures
Other / Miscellaneous
Employee / Affiliate /
Visitor Safety
Professionalism Problems
Equipment / Supplies /
Device Problems
Skin Integrity Problems
Falls
Transfusion Problems
Healthcare IT Problems
If you are not sure…choose “Other”
These 2 are commonly confused…..see next slide
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Select the form you think is best
 You can type in a word to search for the best choice if you aren’t
sure which form to pick for your report.
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Wait a minute….
 What’s the difference between
Errors related to Tests / Treatments / Procedures
and
Complications of Tests / Treatments / Procedures?
 Did something happen (or nearly happen) because we
made a mistake? Call it an “Error”.
• The wrong medication was ordered or someone forgot to hand-off an
important clinical detail
 Did something happen that we didn’t necessarily cause,
but we didn’t want it to happen? Call it a “Complication”.
• A patient aspirated and was transferred to ICU or had an MI in the OR.
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Where Do All These Names & Categories Come From?
 The naming system is the same one used by the
Pennsylvania Patient Safety Authority.
 It makes our data more reliable.
 We use it for benchmarking our safety performance against
other hospitals in the state
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Wow…I can’t believe he just said that to me…
Professionalism Problems
• Should be reported.
• Your name as the reporter will always remain anonymous. You also
have the option of not attaching your name to the report at all.
• We all have bad days, but unprofessional behavior to colleagues
does not make for a healthy or safe work environment.
• All safety net professionalism reports entered by housestaff will be
reviewed by GME leadership and follow-up will occur.
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Examples of Professionalism Events to Report
 You call in a consult and the fellow from the
consultant service yells at you or refuses to
accept the consultation request.
 An attending intimidates or berates you in
private or in front of other colleagues.
 A nurse refuses to carry out an order that you
place and is unwilling to have the matter
mediated by a supervisor or another party.
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Describe the Event Factually, Don’t
Editorialize or State Opinions
Tell us what happened. JUST THE
FACTS. KEEP IT SHORT. Don’t blame people or
say what you think should or shouldn’t have
happened. You will get a call if more
information is needed.
Choose the Harm Score that best
matches your report. The
definitions are right on the form.
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What is a “Harm Score”?...Sounds Scary!
“Harm Scores” allow us to
categorize each event
and track our safety
performance over time.
We understand that these
are new terms and
sometimes you might not
be sure which category to
choose…..
If you aren’t sure, don’t agonize
over it…just give it your best guess!
If the reviewer of the event wishes
to change the score, they can.
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Now, tell us who YOU are & your department
Listing your role and department helps us
provide you and your residency program
leaders with feedback
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Now tell us who was affected….
Did the event affect an
inpatient, an outpatient
or an employee?
If a patient was
affected, the rest of
the info will auto
populate by
entering the
medical record
number.
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And finally, tell us where it happened:
This is really important! The
department, service, and location
you choose determines who
receives your report. Who “owns”
the problem? Who should work
on solving the problem? Where
did most of the problem happen
or begin?
For example, let’s say you want to report a problem with a newly admitted
patient. The emergency room sent the patient upstairs with the wrong medication
hanging on the IV pole. The problem happened in the Emergency Room, but was
discovered on the floor. The nurse manager in the Emergency Room (not on the
floor) needs to look into this error…. So choose the Emergency Medicine as the
Service and Department and the Emergency Room as the location.
(But don’t worry if you choose incorrectly – the nurse manager on the floor will
know to send it to the Emergency Room if you pick the wrong location)
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(If you get interrupted,
you can save it as
incomplete by clicking
on More Actions. Just
remember to come back
later to finish the
report.)
That’s it? I’m
done?
Wow - that
was easy!
When your form is
complete, click SUBMIT
and you are done!
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Before I hit submit…I wonder who reads these?
A bunch of people!
1 - Risk Manager – a nurse with expert training in healthcare risks and
patient safety
2 - Manager on the Floor/Area Where the Event Occurred – they oversee all
events that occur on their unit
3 – Quality & Safety Project Manager – individual who works with the hospital
to improve quality & safety
4 – Physician leaders for quality & safety in the hospital and in your
department
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WAITAAMINUTE.
MINUTE!
WAIT
What
How happened
do I find out to
what
happens
to
my
report?
I want
my report? I want
something
done
something
about done
it!
about it.
There are 4 ways you can find out what happened to your report:
1) When you hit SUBMIT you will get an email with the name and phone
number of a person you can contact with follow-up questions or
concerns.
2) You can see who is managing your report in your InfoCenter list.
3) When your report is closed, you will get another email with the name
and phone number of a contact person.
4) Your residency program leadership will begin to receive regular
reports on events that happened in your area or were reported by you
or your colleagues– ask them to share the information with you if they
don’t already do so.
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And that’s Safety Net!
We know you are
busy saving lives…
we appreciate you
taking the time to
learn to use the
Penn Medicine
Safety Net.
Healthcare is so complex…
we all have to take the time
to report problems so we
can improve and make our
work easier, more
satisfying, and safer for
patients.
Thank you!
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Penn Medicine Safety Net
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