The Patient Safety Organization Privacy Protection Center (PSOPPC) was created to support the implementation of the Network of Patient Safety Databases (NPSD) as authorized by the Patient Safety and Quality Improvement Act of 2005. Healthcare providers submit patient safety event data to Patient Safety Organizations (PSOs), who in turn submit standardized versions of these reports to the PSO Privacy Protection Center (PSOPPC). Why is this important? Because the PSOPPC aggregates and “de-identifies” the data and publishes it to provide a national-level perspective of patient safety events and their contributing factors.

Again, you ask, “why is this important”? Because analyzing these data enables the identification of opportunities for improving patient safety and healthcare quality! This organization used “Frequent Pattern Mining” to assist in their research. Frequent Pattern Mining has been widely used in various applications and for our purposes it allowed the researchers to identify commonly used “single interventions” among all the events, then the algorithm searched for common combinations of two interventions, then continued to find common combinations of three, four, or more interventions co-occurring. What they identified was that commonly reported interventions are similar across all patients.

At the end of the day, here is the key takeaway, interventions in place to prevent falls were similar:

• Across senior and adult patients even though seniors have much higher rates of harm and injury from falls.
• Between patients with and without sensory impairment even though rates of harm and injury from falls are higher among patients with sensory impairment.
• Between patients on medications known to increase the risk of falls and patients not on these medications, even though rates of harm and injury from falls are higher among patients on medications known to increase the risk of falls.
• Across patients with and without a history of falls even though rates of harm and injury from falls are higher among patients with a history of falls.

Well, that doesn’t sound good and in fact is a little troubling! Remember, this is data from you, your fall statistics, your neighbor’s fall statistics, all gathered in one place and the aggregate data shows overwhelmingly that there is room for improvement. Why not share this information, review it with your fall committee, how about the QAPI committee? You may find a PIP is in order and what a beautiful thing if you can improve outcomes! It may also be beneficial to initiate a history of past-non-compliance? I know we can do better, use the HealthCap Resource and Education Center for resources and let’s get to work!