QUALITY & PATIENT SAFETY

Patient Safety

Incidents (PSIs)

What they are — and when to submit one

NYU Langone / Bellevue | Chief Resident, Quality & Patient Safety

Step 1

Navigate to the PSI Reporting Portal

Tools →JPSR Patient Safety Report

Step 2

Homepage → Login with PIV

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Step 3

Fill in Report

Step 4

Location: Either type in “New York” or “630” and specify unit

WHAT IS A PATIENT SAFETY INCIDENT?

A Patient Safety Incident (PSI) is any unintended or unexpected event that could have harmed, or did harm, a patient — including near misses, unsafe conditions, and adverse events.

Near Miss

Error occurred but did NOT reach the patient

(e.g., wrong drug caught before administration)

Unsafe Condition

A situation that increases the risk of harm

(e.g., broken equipment, staffing gaps)

Adverse Event

Harm DID reach the patient

(e.g., medication error causing injury)

PSIs cover ALL patients — inpatients, outpatients, and visitors.

WHAT MAKES A GOOD PSI REPORT?

A good PSI report is factual, specific, and focused on the system — not the individual.

✔ DO

Stick to facts Describe what happened objectively. "Patient received 10 units insulin instead of 1 unit" — not "nurse made a mistake."

Include context Time, location, who was involved (by role, not name), and what was happening at the time.

Document immediate actions Note what was done right away: medication held, attending notified, patient monitored.

Report close calls too Near misses are just as valuable as adverse events — they reveal system gaps before harm occurs.

✖ DON'T

Name individuals Use roles: "the covering resident," "the bedside nurse" — not names. The investigation team has access to records.

Editorialize or assign blame "This was clearly negligent" or "X should have known better." Stick to what happened.

Include extra PHI MRN is sufficient. Don't add patient name, DOB, or other identifiers beyond what's needed.

Wait too long Memory fades. File within 24–48 hours. If unsure whether to report — report first, ask questions after.

⚠ PSI reports are reviewed and investigated, so even if submitted anonymously you may be contacted. Write professionally and factually.

WHAT GETS REPORTED — AND WHERE?

Submit as PSI

• Medication error (wrong drug, dose, route, patient, or time)
• Procedure complication not expected for clinical context
• Delay in diagnosis or treatment causing harm
• Critical lab value not communicated in time
• Near miss — any of the above caught before reaching patient
• Equipment failure leading to harm or near-miss
• Lines or tubes used prior to placement confirmation
• Lab values uploaded to wrong chat
• Inadequate staffing leading to delays in treatment

Escalate to Leadership

Site Director, APD, or Chief Resident

• Interpersonal conflict between residents or with an attending
• Concerns about supervision adequacy or patient load safety
• Mistreatment, discrimination, or unprofessional behavior
• Systemic scheduling or duty hour concerns
• Resident in distress or wellness concerns
• Program-level policy

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No Report Needed

Expected or routine clinical course

• Expected side effects of a medication (e.g., nausea with opioids)
• Anticipated complication of a procedure (documented in consent)
• Death expected given underlying illness trajectory
• Lab trend consistent with known disease progression
• Patient declines recommended treatment (documented refusal)
• Routine care delay due to patient factors (NPO, transport, availability)
• Adverse outcome despite correct management and judgment

Why Reporting Matters

📊

Systems, not individuals�PSIs reveal patterns that no single provider can see. Aggregate data drives systemic fixes.

🛡️

Non-punitive by design�Safety reporting is protected and confidential — it is not a disciplinary mechanism.

🔄

Closes the loop�Reports feed into root cause analysis (RCA), M&M conferences, and QI initiatives that change practice.

📋

Meets accreditation standards�TJC and CMS require robust safety event reporting. Your report supports institutional compliance.

See something → Say something → Submit something

• If you want help, don’t have time, or are worried about something submitted under your name, talk to me!
• I am available any day to help you do your part to make our healthcare safer

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Joshua Ross

Cell: 201-562-7296

Email: Joshua.Ross@nyulangone.org

Office: VA Hospital, 10th Floor South, Room 10-057S (Night Float Room)