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PA - PSRS. Pennsylvania Patient Safety Reporting System. Alan B.K. Rabinowitz Administrator, Patient Safety Authority * * * 2 nd Annual Betsy Lehman Center Patient Safety Conference December 5, 2005. Pennsylvania: Background for State Action.

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pennsylvania patient safety reporting system


Pennsylvania Patient Safety Reporting System

Alan B.K. Rabinowitz

Administrator, Patient Safety Authority

* * *

2nd Annual Betsy Lehman Center Patient Safety Conference

December 5, 2005

pennsylvania background for state action
Pennsylvania: Background for State Action
  • Escalating Medical Malpractice Insurance Premiums
  • Alleged Physician Exodus
  • Threatened Closure of Hospital-based Clinical Services
  • IOM Report (1999): “To Err Is Human”
act 13 medical care availability and reduction of error act of 2002
Act 13: Medical Care Availability and Reduction of Error Act of 2002
  • To reduce and eliminate medical errors by identifying problems and implementing solutions that promote patient safety
  • Establishes the Patient Safety Authority
  • Promulgates facility-based reporting requirements
  • Mandates written patient notification and designation of patient safety officers, plans and committees
  • Administrative provisions, including patient safety CME requirements and self-reporting
  • Medical malpractice-related and tort reform provisions
pa patient safety authority
PA Patient Safety Authority
  • Independent agency under an 11-member Board
  • Non-regulatory
  • Dedicated funding stream outside of the General Fund
  • Collects, analyzes and evaluates trends of serious events and incidents
  • Makes recommendations for improvements in healthcare practices
  • Advises facilities on matters related to patient safety
  • Issues an Annual Report
pa reporting components
PA - Reporting Components

Types of Events

Who Reports

Other Considerations

Acute Care Hospitals

Ambulatory Surgical Facilities

Birthing Centers

Near-Misses (“Incidents”)

Adverse Events(“Serious Events”)

[Infrastructure Failures]


Incidents and Serious Events to PSA

Serious Events and IFs to DOH


No Individual Identifying Data

Confidentiality Provisions


Whistleblower Protections

Facility assessment

pa psrs achieved goals
PA-PSRS: Achieved Goals

Implement Mandatory Reporting

  • Initiated June 2004; Today: 446 facilities; 220,000 reports submitted
  • Web-based; 21 core questions: harm score, root causes and contributing factors, recommendations for prevention

Assure Facilities’ Return on Investment

  • Real time feedback to individual facilities
  • Internal analytical tools and data export capacity
  • Share Lessons Learned and Best Practices: Quarterly and Supplementary Patient Safety Advisories
  • Annual Report
recent advisory topics
C-Diff: A Sometimes Fatal Complication of Antibiotic Use

A Different Mindset: One Facility’s Experience with the Anonymous Report Process

Forgotten But Not Gone: Tourniquets Left on Patients

PCA By Proxy: An Overdose of Care

Skin Integrity Issues Associated with Pulse Oximetry

Medication Errors Linked to Name Confusion

When Patients Speak-Collaboration in Patient Safety

Changing the Culture of Seclusion and Restraint

Complexity of Insulin Therapy

Problems Related to Informed Consent

Risk of Fire from Alcohol-Based Solutions

Confusion between Insulin and Tuberculin Syringes (Supplementary)

The Role of Empowerment in Patient Safety

Risk of Unnecessary Gallbladder Surgery

Changing Catheters Over a Wire (Supplementary)

Abbreviations: A Shortcut to Medication Errors

Focusing on Eye Surgery

Recent Advisory Topics
pa psrs ongoing goals
PA-PSRS: Ongoing Goals

Promote Education and Training

  • Root Cause Analysis: Targeted to Patient Safety Officers
  • Patient Safety Concepts: Culture of safety, legal principles, best practices, national initiatives: Targeted to executives, CMOs and physician champions
  • Promote Culture Change: Targeted to Trustees

Encourage Research

  • Develop Protocols Governing Access to Data

Facilitate Data Sharing

  • Partner with other Data Collection and Research Entities
psa assessment lessons learned
Mandatory reporting vs. conventional wisdom

Volume indicates good “buy in”

Help-Desk queries and facility feedback = user satisfaction

Value of near-miss reporting

Encourages communication and empowerment

Application of Patient Safety Advisories

Promotes internal QI and patient safety initiatives

Everything You Need to Know You Learned from Your Grandmother


Adequate funding

Aesop’s Fable: The Tortoise and the Hare

PSA Assessment: Lessons Learned
psa some additional questions
PSA: Some Additional Questions

Are We Safer Today than We Were in 1999?

  • Yes, maybe, but…..
  • The PA experience
  • Level of provider commitment
  • Pace of change
  • Same old/same old
  • Driving forces

Impact of S. 544 (PSQIA of 2005)

pa patient safety authority12
PA Patient Safety Authority