UF&Shands wins second place and $15,000 in national patient safety challenge

To err is human. But if a hospital is able to understand what contributes to human error, it can help save lives.

This month, the Sebastian Ferrero Office of Clinical Quality and Patient Safety at UF&Shands, the University of Florida Academic Health Center, won second place in a national competition aimed at reducing medical errors. The competition was held by the U.S. Department of Health and Human Services and the Office of the National Coordinator for Health Information Technology. The prize was $15,000.

Thirty-six teams competed in the Reporting Patient Safety Events Challenge, a contest managed by Health 2.0, a conference, media and innovation consulting company.

“The competition is always intense,” said Jean-Luc Neptune, senior vice president of Health 2.0. “This was a hard-won battle.”

The winners, chosen by a panel of independent judges, were announced Thursday.

“Winning this award is a significant accomplishment,” said Linda Allen, team leader and quality systems manager at Shands. “This national recognition validates that UF&Shands is on the cutting edge of reporting adverse events.”

The contest, which launched in April, asked multidisciplinary teams to create an application that simplifies the reporting of “adverse events” in health care. Adverse events are medical errors that harm — or potentially can harm — a patient. For example, a patient undergoes surgery and gets an infection while recovering at the hospital. Near misses, such as almost administering the wrong medicine, are also considered adverse events.

Most hospitals, including Shands, track adverse events. The resulting data, which includes relevant information about the patients and events, is collected and analyzed to make system improvements.

“We don’t view adverse events as an individual’s error; we see it as a system failure,” Allen said. “By analyzing this information, it helps us identify where we have a problem.”

Before implementation of the Patient Safety Act of 2005, hospitals were reluctant to share adverse event data with each other for fear of litigation, hospital representatives say. The act created patient safety organizations, a mechanism for health care systems to voluntarily — and securely — share adverse events. Now, institutions participating in a patient safety organization can learn from each other without fear of legal discovery.

There are 75 patient safety organizations in the U.S.; Shands is a member of one that serves academic medical centers. Pooling data about medical errors and safety hazards allows institutions to improve the quality of health care services and reduce patient risk.

To make it easier for patient safety organizations to file adverse event reports and improvements implemented, the Agency for Healthcare Research and Quality sponsored the Reporting Patient Safety Events Challenge to replace its paper-based system with a computer-based application. Entrants needed to streamline the reporting process while using the agency’s official formats. UF&Shands partnered with the vendor IDinc, a Florida-based software developer specializing in risk management, to design its entry.

“This was a major upgrade to the current software to accommodate the features required to be competitive for this challenge,” said Didier Salem, CEO of IDinc. “The cooperation between Shands and our company has been extremely productive and obviously effective.”

First place went to the Houston-based team, KBCoreSM.