The Patient Safety Authority is an independent state agency established under Act 13 of 2002, the Medical Care Availability and Reduction of Error "Mcare" Act. It is charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety in hospitals, ambulatory surgical facilities, birthing centers and certain abortion providers. Its role is non-regulatory and non-punitive.
The Authority initiated statewide mandatory reporting in June 2004, making Pennsylvania the only state in the nation to require the reporting not only of Serious Events but also near misses. All reports are confidential and non-discoverable, and they do not include any patient or provider names.
A Successful Beginning – A Plan to Achieve Since its inception, the Patient Safety Authority has primarily been focused on development and implementation of the Pennsylvania Patient Safety Reporting System (PA-PSRS), review and analysis of reports submitted through PA-PSRS, and the distribution of guidance primarily through the Patient Safety Advisory.
The Patient Safety Authority made tremendous strides in fulfilling its mission and in the short time of its existence, has been recognized as a leader in patient safety data collection, analysis and guidance.
In 2007, the Patient Safety Authority Board determined that the Authority should do more to advance patient safety in Pennsylvania. The Board embarked on a strategic planning exercise. They listened to stakeholders, experts and staff. The outcome of this exercise is a strategic plan that the Board believes will guide the Authority’s activities for the next several years.
The Strategic Plan organizes the Authority’s objectives and priorities into a series of initiatives.
These initiatives will be implemented over several years and will be allocated appropriate funding. The 11 initiatives follow:
• Initiative A: Educate Executive Management and Boards of TrusteesImplementing the strategic plan initiatives has been a priority in the second half of 2007. For example, The Authority is working with the Hospital and HealthSystem Association of Pennsylvania (HAP) and the American Hospital Association (AHA) to develop/adopt a curriculum for Pennsylvania's CEOs and boards of trustees to understand their role in patient safety. Nursing home data and HAI prevention initiatives are being addressed through the implementation of Act 52. The Authority also met with several Patient Safety Officers throughout the year to present ideas and obtain feedback. These efforts support another strategic plan initiative regarding development of the Pennsylvania Knowledge Exchange (PasSKEy). This electronic confidential forum would allow Patient Safety Officers to discuss problems and share written solutions in their facilities freely with one another to improve patient safety. Also geared toward helping facilities improve patient safety, the Authority plans to hire Patient Safety Liaisons to go into facilities and help them implement better system processes. The PSLs would also obtain valuable feedback from the facilities to learn how the Authority can help them further. The Authority will also hire a Director of Education Programs. For more information on the Authority's Strategic Plan, go to page 12 of this annual report.
• Initiative B: Infection Awareness and Reduction
• Initiative C: Patient Safety Knowledge Exchange (PasSKEy)
• Initiative D: Improve Reporting Consistency and Recommendations
• Initiative E: Increase Effectiveness through Extended Presence
• Initiative F: Governor’s Office of Healthcare Reform (GOHCR) Collaboration
• Initiative G: Data Collaboration
• Initiative H: Patient Safety Methods Training
• Initiative I: Nursing Home Data Analysis
• Initiative J: PA-PSRS System Enhancements
• Initiative K: Maintain Success of Patient Safety Advisory
Reducing Infections through Act 52
In July, Act 52 of 2007 gave the Authority responsibilities related to the prevention of healthcare-associated infections (HAI) in Pennsylvania. Specifically, the Act calls for the Authority to work with the Department of Health and the Pennsylvania Healthcare Cost Containment Council to collect infection data through the Centers for Disease Control and Prevention reporting system. To eliminate duplicate reporting, the Authority modified the CDC system to satisfy the reporting requirements for hospitals. Hospitals began reporting through NHSN on February 14, 2008.
The Act also requires the Authority to collect HAI reports from the approximately 800 Pennsylvania nursing homes. The Authority is working with the Department of Health to identify what information will be collected and the collection systems and processes. It is anticipated that the nursing homes will be reporting infections by the end of 2008. The Authority has also been charged with analyzing the infection data for Act 13 facilities and nursing homes and making the Patient Safety Advisories available to all.
In accordance with Act 52, the Authority established a panel of HAI experts to provide guidance for the effort to combat infections in Pennsylvania’s hospitals and nursing homes. While developed and managed by the Authority, the Advisory panel is available to counsel all state agencies with responsibilities related to Act 52. More information about Act 52 and the Advisory
Data Collection - Patterns and Trends in Reports Collecting and analyzing reports of Serious Events and Incidents are vital components to the Authority’s educational initiatives. The reports are submitted through the Pennsylvania Patient Safety Reporting System, known as PA-PSRS.
The data was submitted by Pennsylvania’s 511 hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities. These facilities submitted 211,983 reports; 7,277 were classified as Serious Events (adverse events with patient harm) and 204,706 classified as Incidents (near misses and events that reached the patient but did not cause harm) into PA-PSRS in 2007. Almost 97% of the events in 2007 were classified as Incidents. The Authority believes that robust submission of Incident reports generally indicates a positive culture of safety within a facility that reflects open communication and attention to patient safety efforts. In Figure 1, report volume in 2007 showed an increase of 16,151 reports over 2006, with an increase in both Incidents (8%) and Serious Events (5%).
When reporting an event to the Authority, a facility uses a classification system or "taxonomy" to characterize the occurrence they are reporting. A facility classifies a report by identifying what PA-PSRS defines as the "Event Type." The Event Type essentially answers the most basic question about an occurrence: "What happened?" While there is considerable detail within the taxonomy, at its most basic level, the PA-PSRS classification contains nine Event Types.
Other highlights of data submitted through PA-PSRS during the calendar year 2007 are:
• 512 hospitals, ambulatory surgical facilities and birthing centers were subject to Act 13 reporting requirements. They submitted 211,983 reports of Serious Events and Incidents through PA-PSRS, an increase of 16,151 reports or 13% from 2006.
• Almost ninety-seven (96.6) percent of all reports were Incidents, in which the patient was not harmed; approximately 3.4% of all reports were Serious Events, which indicates that the patient received some level of harm, ranging from minor, temporary harm to death. Incident reports increased 8% over last year. Serious Event reports increased 5%.
• Reports from hospitals accounted for 98.7% of all reports submitted.
• Women patients were more involved in reports (54.4%) than men (45.6%). Women are more likely to use the healthcare system during childbearing years. They also have a longer life expectancy than men and therefore are using the health system more.
• Adverse Drug Reactions for women were 63%, while for men they were 37%.
• Children and adolescent (aged 21 and younger) reports increased by 3.3% in 2007.
• Patient Falls accounted for 17% of all reports, a decrease from 21% in 2006.
• While Complications related to Procedures, Treatments or Tests accounted for just 15% of overall reports, they accounted for 44% of reports in which a patient was harmed and 59% of all reports of events resulting in or contributing to a patient’s death.
• Elderly reports have maintained a consistent pattern. More than half of all reports (52.7%) involve elderly (age 65 and over) patients, down slightly from 2006 (53.1%). Elderly patients accounted for 61.2% of Falls in 2007, a drop from 2006 (62.4%). Elderly patients accounted for 73.1% of reports related to Skin Integrity in 2006, this figure increased slightly in 2007 to (73.5%).
• Medication Errors accounted for 22% of all reports (slight decrease from 2006), and they represented only 1% of all Serious Events. Although most Medication Errors involve adults, Medication Errors involving children and adolescents were more likely to result in patient harm.
