Patient Safety Initiative - Case Review System

Frequently Asked Questions

1. What is the purpose of the Patient Safety Initiative – Case Review System?

2. I was not able to enter the findings from my case review on the screen. Why?

3. What is the difference between “Unassigned” and “Unreviewed” cases in my Worklist?

4. A case was sent to me to review when it should have been referred to a reviewer from another service. Why does this happen and what should I do?

5. What diagnoses does the PSI- CRS use to identify each adverse event from the hospital billing data?

6. In the Final Disposition section of the case review, when should I refer the case to Risk Management or the Patient Safety Committee?

7. Is there a way to reduce the amount of time I spend reviewing a patient’s CareWeb records in order to find the information I need about the adverse event?

8. How can I send a case summary to a resident so that the case can be discussed at a departmental M&M?

 

 

 

1. What is the purpose of the Patient Safety Initiative – Case Review System?

The purpose is several-fold: a) improve patient safety by identifying adverse events from hospital billing data, many of which are not reported to Risk Management via the voluntary Patient Safety Reporting System, b) identify and correct diagnosis coding errors, c) reduce our exposure to financial penalties under the new Medicare reimbursement policy that reduces payments to hospitals when a hospital-acquired condition occurs.

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2. I was not able to enter the findings from my case review on the screen. Why?

You probably opened a “view only” copy of the case. A “view only” copy is displayed after you click on the link from your e-mail notification and login to the PSI- CRS. To access a copy of the case that you can use to enter your findings, you must first go to the Worklist, find the case in your list of “Unreviewed Cases” and click the “Review” button, which appears in the last column on the right.

A “view only” copy is also displayed when you click on a case in your “Unreviewed Cases” in your Worklist, but do not specifically click the “Review” button.

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3. What is the difference between “Unassigned” and “Unreviewed” cases in my Worklist?

Unassigned cases are cases that were referred to at least one other designated reviewer from your clinical area. You or one of your colleagues must click the “Assign to Me” button in the right hand column. This action puts the case into your list of unreviewed cases.

Unreviewed cases are cases that were referred to you or that you assigned to your worklist but have not been reviewed. Begin reviewing a case from the unreviewed case list by clicking on the “Review” button in the right hand column.

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4. A case was sent to me to review when it should have been referred to a reviewer from another service. Why does this happen and what should I do?

The PSI- CRS uses an algorithm to identify the clinical service where the adverse event probably occurred and refers the case to a designated reviewer from that service. It was necessary to develop this algorithm because there are no dates associated with the ICD-9-CM diagnosis codes that could be used to pinpoint the patient’s location when the adverse event occurred.

Sometimes the algorithm will cause a case to be referred to the wrong service. Under these circumstances, you should select Review Decision 5 so that the System Administrator can reassign the case to a reviewer from the proper clinical service. Please enter your rationale for selecting this option in the Findings section.

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5. What diagnoses does the PSI- CRS use identify each adverse event from the hospital billing data?

The list of diagnoses that are used to identify each of the adverse events that the PSI- CRS refers for investigation are presented in “Definitions and Specifications” of the Help section.

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6. In the Final Disposition section of the case review, when should I refer the case to Risk Management or the Patient Safety Committee?

Refer the case to Risk Management to communicate your concerns about the possible occurrence of a medical mishap. Refer the case to the Patient Safety Committee if you believe that the adverse event might have occurred as a consequence of a systems problem that should be addressed and resolved across the organization.

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7. Is there a way to reduce the amount of time I spend reviewing a patient’s CareWeb records in order to find the information I need about the adverse event?

One option is to use “EMERSE” (The Electronic Medical Record Search Engine). This is a tool that can help you find the sections of a patient’s CareWeb records that pertain to the adverse event. In essence, it is a tool that allows you to search for key words in the CareWeb records.

If you wish to obtain access to EMERSE and learn to use it, please contact David Hanauer, MD by e-mail (Groupwise or hanauer@med.umich.edu) or by phone (734-615-0599).

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8. How can I send a case summary to a resident so that the case can be discussed at a departmental M&M?

You can send a PDF file of the case summary. Simply open a “view only” copy of the case by clicking on a case from the list of “Unreviewed Cases” in your Worklist, (Click anywhere in the row that lists the case, but do not click the “Review” button) Once you have opened the “view only” copy, scroll to the bottom and click on the “Show PDF” button on the left-hand corner

(Note: You can not refer the case to anyone else to conduct the review unless you and the other individual are given the proper roles within the PSI- CRS)

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