Going from Good Catch to Quality Improvement
Michael Colligan, DHA, RN, CCP
Near-miss and serious adverse events are reported to happen frequently during cardiac surgery, with estimates for near miss events being as frequent as 1:138, and “serious injury or death” events happening as frequently as 1:1000. These numbers are significantly higher than many other specialties in health care and have led many prominent perfusionists to call for a prospective national reporting system to capture near-miss and patient harm incidents that occur during clinical practice in the United States.
In March of 2022, AmSECT partnered with Orrum Clinical Analytics to adopt a PSO protected national incident reporting system for perfusion and cardiac surgery. Since that time, the number of unique event reports has grow from zero to near triple digits and the ability to adapt the knowledge garnered through these reports has become a pressing issue.
Here we present a brief history of the development of the PSO protected incident reporting system, it’s adoption by AmSECT, and provide a summary of the numbers and types of incidents reported to date. Finally, we conclude by sharing qualitative themes that have emerged from the reporting and analysis of these events and how these themes can help us to move from good catch to quality improvement.
Michael Colligan is a Certified Clinical Perfusionist and Registered Nurse. Michael designed and built the first and only Patient Safety Organization for cardiac surgery, the Orrum PSO, which in 2022 became the official incident reporting system of AmSECT. Currently, Michael serves as the executive director of the Orrum PSO and is working on developing novel, evidence-based guidelines for perfusion training, real-time clinical decision support, equipment design and selection, and validated simulation programs.
