ORRUM
PATIENT SAFETY ORGANIZATION (PSO)
Developing a multi-component incident reporting system for use by perfusionists around the world.
FILLING THE PATIENT SAFETY GAP
For nearly 20 years, prominent perfusionists have called for a perfusion-centric prospective incident reporting system to collect near-miss and patient harm incidents that occur during clinical practice in the United States. Today, Orrum PSO enables the perfusion community to answer the call.
THE FIRST AND ONLY PERFUSION-CENTRIC
PSO IN THE WORLD
Perfusion departments and medical centers are continuously seeking methods to improve patient safety. Today, by leveraging the power of computing with the shared experience of providers across the country, a new level of patient safety is becoming a reality. Data from voluntary incident reports are coupled with the most advanced sensor technology available to develop a comprehensive analysis of events.
HARNESSING CLINICAL DATA FOR IMPROVED PERFUSION PATIENT SAFETY
INFORMATIVE DATABASE
Provides immediate improvement in patient safety standards. Data is collected from a national database then analyzed and condensed into actionable recommendations.
UPDATES AND ALERTS
With quarterly updates and immediate alerts about serious incidents, perfusion teams can stay one step ahead of costly and potentially life-threatening events.
DIGITAL DATA CAPTURE
Advanced IoT data capture technology enables real-time, highly detailed analysis of any OR environment. This represents the pinnacle of perfusion safety and performance improvement.
HOW DOES ORRUM PSO WORK?
Sign up for membership in the Orrum PSO.
Receive quarterly reports and timely alerts regarding key safety events.
Submit incident reports as needed and receive an analysis of your event based on best practices, and the knowledge gained from hundreds of providers across the country.
PSO BENEFITS
REAL WORLD ISSUES
Quantifying the number and type of incidents allows clinicians and educators to understand real and current risks. Subsequent adjustments to clinical practice and training address actual on-the-ground scenarios.
DEMOCRATIZATION OF KNOWLEDGE
The collective effort of perfusion centers across the county leads to improved safety and quality. Smaller perfusion programs have access to the same information as major centers, allowing all providers to elevate performance.
BROAD-BASED IMPROVEMENTS
A thriving PSO expands the understanding of best practices in training, equipment use, system design, and simulation scenarios.
PROACTIVE, NOT REACTIVE
Data aggregation from large numbers of incidents helps clarify what safety initiatives are working and which ones might need revision. This represents a shift from case-based, retrospective reporting to trend-based, prospective reporting.
COMPLIANCE
The Orrum PSO is listed with the U.S. Department of Health and Human Services Secretary as a Patient Safety Organization (PSO).
PSO SOLUTIONS
INCIDENT REPORTING
Allows clinicians to report near-miss and patient harm events via an anonymous, secure, online portal from anywhere in the U.S. Every event reported contributes to learning. An individualized analysis is provided for each event including suggestions for interventions to mitigate risks. These suggestions are based on aggregated data from over 100 institutions. Providers help each other by reporting near-miss and patient harm events so mistakes are not repeated.
SIMULATION AND CRISIS MANAGEMENT TRAINING
On-site and remote simulation and crisis management training are available based on real-life incident scenarios. Participate in crisis management simulations without worry that your performance can be audited via legal discovery (protected by the Patient Safety Act of 2005). Simulations and training address the specific scenarios you are likely to face, instead of those based on textbook knowledge or simulator design.
SAFETY ASSESSMENTS
On-site and virtual assessments of clinical standards, practices, and management are based on reports received from across the country. Comparison of current practice to other similar institutions and best practices established by analyzed event reports. This moves the focus from management of risk to improvement in training, equipment, and system design.
ADVANCED CLINICAL DECISION SUPPORT (COMING SOON)
Near-real-time clinical decision support integrated into your Electronic Health Record (EHR) to provide guidance at the instant when you face a rare complication. Receive tips on how to proceed, what to watch out for, and the most viable solutions available.
LEARN HOW THE ORRUM PSO
WAS DEVELOPED
Orrum PSO is the world’s first perfusion-centric prospective incident reporting system to collect legally protected patient safety event data that occurs during clinical practice in the United States.
Read this in-depth review about how the Orrum PSO was developed and the multiple benefits it provides to all participating perfusion teams.
PSO FAQS
What is the Orrum PSO?
The Orrum PSO is a Patient Safety Organization that has undergone review by the Agency for Healthcare Research and Quality (AHRQ) and is an officially listed PSO with the United States Department of Health and Human Services (HHS). After initial listing, PSOs self-certify every three years with the AHRQ. Attestations and disclosures in the self-certification support the use of professionally recognized standards and the fair and accurate performance of patient safety activities among providers with or without relationships to the PSO. See our official listing page here https://www.pso.ahrq.gov/pso/orrum-pso
What types of events can I report to the Orrum PSO?
The Orrum PSO accepts reports of any Non-Routine Event (NRE) that occurs in or around extracorporeal support procedures including cardiopulmonary bypass, ECMO, Ventricular Assist Devices, Isolated Limb Perfusion, Ex Vivo organ perfusion, HiPEC, and/or autotransfusion/cell salvage. A Non-Routine Event (NRE) is defined as anything that is not normal or that you would not want to have happen again. No harm, near miss, and sentinel events can all be submitted.
Who sees identifying information I submit to the Orrum PSO?
The only persons with access to identifying information submitted to the Orrum PSO are Orrum PSO employees who: (1) have been trained on event analysis, (2) have been educated on the confidential, secure, and non-discoverable nature of patient safety work product, and (3) have signed a confidentiality agreement stating they will only disclose patient safety work product as authorized under the Patient Safety Act. All Orrum PSO analysts are active clinicians with experience in the specific techniques and equipment used in each event report.
What legal protections are provided to information submitted to the Orrum PSO?
Information submitted in good faith to the Orrum PSO is protected by the Patient Safety Act of 2005. This means the data is both privileged and confidential indefinitely. The PSO legal framework, in addition to providing protections from discovery, creates substantial penalties for the release of identified information (up to $11,000 per occurrence). Information submitted to the PSO remains inadmissible in court even if lost or stolen. Learn more about the legal protections of the Patient Safety Act here https://www.pso.ahrq.gov/faq
Can I submit reports anonymously?
There are two ways to submit anonymous reports. PSO members can submit a report inside the Orrum Clinical Analytics portal and check the box requesting the report be made anonymously. Alternatively, those who are not members of the PSO can submit reports through our confidential and secure website perfusionsafety.org
What type of Information Technology (IT) is used to submit reports?
The Orrum PSO has partnered with a large, well-known risk management firm to develop our reporting platform. The reporting system is in compliance with a variety of security standards, including Authorization to Operate (ATO) under the Federal Information Security Management Act (FISMA) Moderate System Authorization and Accreditation, compliance with NIST 800-53, known as the HIPAA Security Rule, self-certification to the U.S. Department of Commerce that it adheres to the E.U.-U.S. Privacy Shield Principle, and independent audits confirming compliance with the American Institute of Certified Public Accountants (AICPA) Trust Services Security and Confidentiality Principles and Criteria.
What happens to information I submit to the Orrum PSO?
The information you report to the Orrum PSO will be analyzed by an experienced perfusionist (or appropriate alternative clinician) who has training in standardized event analysis. The knowledge learned from the analysis will be used to help perfusionists improve care through dissemination of lessons learned, best practices, and checklist recommendations. Aggregated, non-identified data may be provided in feedback to manufacturers, professional organizations, and Health Information Technology (HIT) providers in an effort to improve safety and quality in their products. When you submit a Non-Routine Event (NRE) report to the Orrum PSO, you are helping to make extracorporeal support better, safer, and of high quality for all of our patients.
Who can submit reports to the Orrum PSO?
Anyone can submit a report to the Orrum PSO. You do not need to be an Orrum PSO member. Providers who are not members of the Orrum PSO can submit reports through our anonymous reporting link at perfusionsafety.org
What feedback will I get from the Orrum PSO on a report that I submit?
If you submit a report to the Orrum PSO and provide return contact information (phone or email, all of which remain confidential and privileged), the Orrum PSO will return to you an analysis of your event that includes a review summary by two experienced perfusionists, a categorization of the incident using a modified Reason classification system, a list of contributing factors as defined by the Agency for Healthcare Research and Quality (AHRQ) Learn from Defects Tool, comparison of the event against pre-existing standards or policies from the American Society of Extracorporeal Technology (AmSECT) or others, and suggested interventions to reduce the risk of event reoccurrence. As with all data generated from the Orrum PSO, these analyses and recommendations will be based on knowledge gained from aggregating large numbers of rare events.
How can I benefit from being an Orrum PSO member?
While individual event analysis is free to anyone submitting a report, aggregated de-identified data, including lessons learned and recommendations for best practices garnered from all reports, are only distributed to providers who are members of the Orrum PSO. Becoming a member of the Orrum PSO means you gain knowledge not only from the single report you submit, but from all reports that have ever been submitted to the Orrum PSO. While this may sound like an expensive knowledge base to access, basic membership is designed to be affordable for any size group or organization.