Eliminating Serious Patient Safety Events in Surgical and Procedural Areas: A Statewide Conference and Call to Action for California Hospitals - May 14-15

Overview

In 2007, the California Department of Public Health (CDPH) implemented requirements for hospitals to report serious, adverse, highly preventable patient safety events for state investigation. Among the 28 reportable adverse events are five that occur specifically in surgical and procedural settings: retained surgical item (RSI); surgery or procedure on the wrong patient, at the wrong site, or with the wrong procedure; and unexpected anesthesia deaths in healthy patients. RSIs are the most common type of surgical adverse event and the second most frequently reported type of adverse event overall. To date, California hospitals have reported more than 1,500 potential RSIs and more than 500 other potential surgical adverse events to CDPH. These events occur in surgical areas but also frequently in non-operating environments where procedures are performed, such as obstretric/gynecology departments and catheterization labs.

A regulatory reporting requirement should help to spur patient safety improvements in hospitals, yet the number of surgical adverse events reported appears to be increasing. To achieve progress at a state level, a call to action is needed to make better use of the reporting system and to strengthen hospital improvement efforts. With support from CDPH, the Institute for Population Health Improvement (IPHI), UC Davis Health System, is convening a state-of-the art conference that aims to accelerate statewide progress towards reducing the occurrence of serious patient safety events that occur in surgical and procedural settings.

The main goals of this conference are to:

• Identify information and strategies that hospitals and clinicians can use to implement systemic changes to prevent the occurrence of serious, reportable adverse events that occur in surgical and procedural areas; and
• Discuss what has been learned through mandatory adverse event reporting in California, and evaluate opportunities to improve the reporting system so that it better aligns with hospitals’ patient safety improvement efforts.

Target Audience

This conference is aimed at those who can work to implement systemic, sustained changes in California hospitals and other healthcare delivery settings: executive-level hospital administrators, clinicians and administrators working in surgical and other procedural areas (including obstetrics/gynecology, cardiac catheterization labs, and other non-operating room settings); and patient safety/quality improvement professionals.

Continuing Medical / Nursing Education

AMA Category 1 credits will be available for CME/CEU.

Preliminary Agenda

May 14, 10:00 am – 6:00 pm

• Measuring and Reporting Surgical Patient Safety: Views from Hospital, State, and National Levels

• The State Investigation and Reporting Process for Adverse Events: CDPH in Conversation with California Hospitals

• Getting to Zero: Spotlight on State Surgical Patient Safety Initiatives to Prevent Retained Surgical Items

• Initial Recommendations for Hospitals, from the IPHI Patient Safety Advisory Committee

• Reception (5:00-6:00 pm)
  

May 15, 8:30 am – 12:00 pm

• Strategies to Achieve Systemic Change in Surgical and Procedural Patient Safety

• Bringing State-level Organizations Together for Surgical and Procedural Patient Safety in California

• What Can You Do on Monday Morning? Providers Answering the Call to Action
  
  

For additional agenda details, including names of conference speakers, please click here to visit the Institute for Population Health Improvement event page.