Thomas B Kernan, Senior Vice President for Marsh Healthcare in Florida, is actively soliciting participants for the Florida Patient Safety Corporations (FPSC) Near Miss reporting program. The FPSC issued a contract to the JMH/UM Center for Patient Safety, CS Stars, Marsh, and Marsh Risk Consulting Group to develop a web-based system and process analysis for Near Misses submitted by healthcare facilities. Currently there are several openings for hospital participants. Ambulatory Surgical and Birthing Center slots are filled until the next phase of the study.
Over the past 5 months, the system has been built, tested, and is now in use throughout the State of Florida. Several issues have delayed some facilities from joining. On one hand, many hospitals in Florida have or are implementing their own Near Miss system. In these cases it may be possible to avoid dual reporting through the use of technology. This is being currently reviewed. An additional reason is concern about Amendment 7 and its impact on the privacy of hospital data in general. However many hospitals determined that by studying this Near Miss data they will be in better position to avoid a risk from the start. Those participating to date have found the system to be user friendly. It takes a reporter about 2 minutes to answer 8 questions. Once a reporter enters the answers and hits the “submit” button, the information is sent to the hospital in house to review and determine if data are to be sent on to the Center for Patient Safety at JMH/UM. That decision is left to the hospital. An automatic de-identification of data system is activated 72 hours after the hospital submits the data to Dr. David Birnbach, the Centers Director. It is important to note that the Florida Statute defines a Near Miss as “any potentially harmful event, that could have had an adverse result, but, through chance or intervention, harm was prevented.” We are reporting a non-harmful event in order to study, ahead of the incident and claims curve, what interventions could have prevented even a nonevent. Governor Bush Task Force on the Medical Malpractice Crises in 2002 led to the establishment of the Florida Patient Safety Corporation in his 2005-6 budgets. “I applaud the healthcare professionals and institutions that embrace this initiative and demonstrate their leadership and commitment to continued quality improvement.”
