Patient Safety Surveillance and Improvement

The Patient Safety Surveillance and Improvement System (PSSIS) was created for the purpose of improving patient safety, eliminating adverse events in Vermont hospitals, and supporting and facilitating quality improvement efforts by hospitals. The Vermont Department of Health is charged by statute to operate the PSSIS, and contracts with the Vermont Program for Quality in Health Care (VPQHC) to administer the system.

Key Components

Internal Hospital Procedures

Each Vermont hospital must:

  • Establish internal policies and procedures to identify, track and analyze all adverse events and near misses
  • Conduct appropriate causal analysis
  • Develop and implement corrective action plans

External Reports

Each Vermont hospital must report to the Patient Safety Surveillance and Improvement System incidences of any of the National Quality Forum’s serious reportable events and for each event:

  • Conduct an appropriate causal analysis
  • Develop and implement a corrective action plan
  • File the causal analysis and corrective action plan with the Patient Safety Surveillance and Improvement System
  • Each hospital must report any incidence of intentional unsafe acts

Serious Reportable Events in Vermont from the Hospital Report Card

Disclosure to Patients

Each hospital must develop policies and procedures requiring disclosure to patients relating to adverse events that cause death or serious bodily injury.

 

Confidentiality of Information

The Patient Safety Surveillance and Improvement System is designed to improve patient safety. As provided for in 18 V.S.A. §1917, all information made available to the Department of Health through the Patient Safety Surveillance and Improvement System is:

  • Confidential and privileged
  • Exempt from the public access to records law
  • Immune from subpoena or other disclosure and not subject to discovery or introduction into evidence in any civil or administrative action against a provider of professional health services
System Administration and Legislative Authority

The Intentional Unsafe Act provisions of the Patient Safety Surveillance and Improvement System became effective on July 1, 2006, and the remaining provisions on January 1, 2008.

Consumer Information

About the System

The Patient Safety Surveillance and Improvement System is designed to improve patient safety, eliminate adverse events, and support quality improvement efforts by Vermont hospitals. The Health Department is charged by statute to operate the PSSIS, and contracts with the Vermont Program for Quality in Health Care (VPQHC) to administer the system.

Each Vermont hospital must report to the system any incidence of any of the National Quality Forum’s serious reportable events.

Report Abuse or File a Complaint

To report abuse, neglect or exploitation of a vulnerable adult or to enter a complaint against a facility or agency that provides health care, please contact the Division of Licensing and Protection:

Division of Licensing and Protection: Vermont Department of Disabilities, Aging & Independent Living

Phone: 800-564-1612 or 802-241-3918
Fax: 802-241-4092

REPORT ONLINE: Abuse Reporting Online Form

Patient Safety Fact Sheets

Five Steps to Safer Health Care: Patient Fact Sheet
What you can do to get safer health care.

20 Tips to Help Prevent Medical Errors
Be involved in your health care. Here's what you can do.

20 Tips to Help Prevent Medical Errors in Children
Be involved in your children's health care. Here's what you can do.

Hospital Reporting

Each hospital must report the incidence of a National Quality Forum (NFQ) serious reportable event, and the occurrence of an Intentional Unsafe Act to Patient Safety.

The Patient Safety Surveillance and Improvement System (PSSIS) was created for the purpose of improving patient safety, eliminating adverse events in Vermont hospitals, and supporting a facilitating quality improvement efforts by hospitals. The Vermont Department of Health is charged by statute to operate the PSSIS, and contracts with the Vermont Program for Quality in Health Care (VPQHC) to administer the System.

Reporting a NFQ Event or Intentional Unsafe Act

Hospitals may report a NFQ Event or Intentional Unsafe Act by completing the applicable form and sending it to VPQHC. Instructions for doing so are located on the last page of each form.

Reporting Forms:

Casual Analysis and Corrective Action Plan

Intentional Unsafe Act

Reportable Adverse Event

Contact Us

Vermont Program for Quality in Health Care, Inc.
802-229-2759

Vermont Department of Health
Director of Planning & Health Care Quality
802-652-4173