The Pennsylvania Patient Safety Authority has collected over one million reports from Pennsylvania healthcare facilities since June 2004. Ninety-six percent of the events are near misses or events that did not cause harm to the patient.
"The Authority is highlighting the number of reports we received because it gives us an opportunity to raise awareness for facilities to continue to learn from these events and implement change; but it also allows us to reflect on how far we have come in terms of how facilities view reporting today as opposed to five years ago," Mike Doering, executive director of the Pennsylvania Patient Safety Authority said.
Prior to the creation of the Authority and the Pennsylvania Patient Safety Reporting System (PA-PSRS), facilities reported events and infrastructure failures to the Department of Health under what was known as Chapter 51. Once Act 13 of 2002 was enacted creating the Authority, all serious events and near misses were reported through PA-PSRS to the Authority and Chapter 51 went away. The Department of Health continued to receive serious events and infrastructure failures through PA-PSRS for its regulatory purposes.
Doering said under Chapter 51 facilities reported a total of 7,744 events and infrastructure failures in about five and a half years. Conversely, since facilities began reporting through PA-PSRS in June 2004, serious events and infrastructure failures total 446,967. He cites the dramatic increase in reports to the ease of using PA-PSRS and an increased awareness from facilities that reporting matters.
"Through the Pennsylvania Patient Safety Advisory we have been able to show facilities how reporting events can help them learn and implement change to improve patient safety," Doering said. "Hospitals and ambulatory surgical facilities responding to our surveys made over 600 process changes in their facilities in 2008 in direct response to the report data analysis and guidance provided by the Authority."
Doering added that to date the Authority has published over 225 educational articles in its Patient Safety Advisory since 2004. A wide range of topics have been covered with national success. One article highlighting the risks of color coded wristbands sparked a national effort to standardize the meanings and colors.
In December 2005, the Authority published an article about a near miss in one of the facilities where a patient almost died because a nurse confused the meaning of a color coded wristband she placed on the patient. The nurse placed a yellow wristband on the patient thinking it meant "Do Not Take Blood from this Arm" when it actually meant "Do Not Resuscitate." Fortunately, the error was caught and the patient was resuscitated after suffering a heart attack.
The Authority did a survey of the number of colors and meanings facilities used for the wristbands and found there were several colors used by facilities with different meanings depending upon which hospital you were in.
"Shortly after the color coded wristband issue was published, healthcare facilities in northeastern Pennsylvania began to develop protocols for standardization. Those protocols have been adopted in 46 states throughout the country in some form," Doering said. "All states reference the near miss reported in Pennsylvania as the catalyst for making the change to standardize the meanings and colors of color coded wristbands."
Doering said the Authority also brought a national awareness to the issue of wrong site surgery. In June 2007, the Authority published an Advisory article highlighting data that showed an actual or near miss wrong site surgery occurred every other day in Pennsylvania healthcare facilities. Since then, the Authority has seen marked improvement in the reduction of wrong site surgeries in Pennsylvania. Details of the Authority's wrong site surgery educational efforts and new data results are forthcoming.
This year, over 700 nursing homes began reporting healthcare associated infections through PA-PSRS. The Authority worked with its Healthcare Associated Infection Advisory Panel and the Department of Health to develop the reporting requirements. Over 5,000 HAI reports have been submitted by nursing homes since reporting began in June 2009.