Pennsylvania Patient Safety Authority marks one million report milestone

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.

"With the enactment of legislation aimed to reduce healthcare associated infections, Pennsylvania has the distinction of having the most comprehensive healthcare associated infection data reporting in the nation," Doering said. "The enthusiasm shown by nursing homes has been encouraging as the Authority has begun to educate nursing homes on what they can do to prevent infections through Advisory articles. As the data is collected, more information will become available and hopefully the enthusiasm will continue for learning from events and implementing change to prevent healthcare associated infections."

Doering said the Authority has increased its educational efforts by developing a program in which six representatives of the Authority or Patient Safety Liaisons are placed throughout the state in six regions. Led by the Director of Educational Programs, the liaison program was developed by request from a focus group of Pennsylvania patient safety officers who asked for more of a presence from the Authority. Three liaisons are located in the northeast, south central and northwest regions of the state. The Authority plans to hire three more liaisons within the next year.

"The PSL program has been very successful so far," Doering said. "Facilities are communicating with us to let us know what we can do to help them improve patient safety. Conversely, the PSLs are making their facilities aware of information provided in Patient Safety Advisories that will help them implement process changes that will also improve patient safety."

"The liaisons are also increasing and focusing our educational efforts through the information they receive from facilities and have begun regional collaboratives to address specific patient safety issues," he added.

Doering said that communication is almost always a factor when a medical error occurs. To help open the communication between healthcare providers, the Authority is developing a web based program called the Patient Safety Knowledge Exchange (PassKey).

"The program's success will hinge upon the patient safety officers communicating with one another through this website about what works for them and what doesn't in regard to solutions for reducing serious events and incidents in their facilities," Doering said. "Several facilities in the state are doing great things within their own facilities to improve patient safety. PassKey will give them the forum they need to share the information through conversation and written processes that have been implemented so others can learn from their successes or even sometimes failures."

The PassKey program is expected to be in place by the end of 2009.