Case Studies
PSET Pilot Study
The Patient Safety Event Taxonomy (PSET) is a set of national standards conceived by The Joint Commission and endorsed by the National Quality Forum (NQF) to facilitate common data exchange and interoperability between disparate patient safety reporting and learning systems and to generate meaningful transparency in reporting. The Patient Safety Event Taxonomy (PSET) Pilot Study – NQF enlisted Lumetra Healthcare Solutions in pilot-testing PSET in California as a key step to implementation. The contract was funded by the California Healthcare Foundation.
Lumetra engaged numerous key stakeholders to promote patient safety and develop strategies, including hospitals, The Joint Commission, and NQF and facilitated teleconferences for risk event managers who voiced a desire for patient safety forums.
The results of the final study show great variation in existing hospital reporting systems, variable ability to map from existing systems to PSET and the ICPS (International Classification for Patient Safety), and wide discrepancies in the interpretation of the same event scenarios. Specific key findings were presented based on research in four key areas:
- Mapping
- Inter-rater reliability
- Mock scenarios
- Interviews
Lumetra recommended that hospitals:
- Self-evaluate existing reporting systems
- Invest in training of staff using the patient safety reporting system
- Incorporate cultural competency as a part of a standard taxonomy
- Incorporate a narrative into a standard taxonomy
- Draw upon a wide variety of hospital staff to refine PSET and ICPS
- Continue to invest in a national patient safety taxonomy
Through this study, there is evidence that a standardized taxonomy, clearly defined dictionary, and educational component will allow hospitals to benchmark their success, see opportunities for improvement, share best practices, as well as design and implement processes that improve patient safety.
