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Medical Liability & Patient Safety: Pennsylvania’s Experience

Medical Liability & Patient Safety: Pennsylvania’s Experience. NGA Center for Best Practices Health Policy Advisors September 10, 2004. Background. Institute Of Medicine Reports “To Err is Human – Building a safer health system” (1999) “Crossing the Quality Chasm” (2001)

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Medical Liability & Patient Safety: Pennsylvania’s Experience

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  1. Medical Liability & Patient Safety:Pennsylvania’s Experience NGA Center for Best PracticesHealth Policy AdvisorsSeptember 10, 2004

  2. Background • Institute Of Medicine Reports • “To Err is Human – Building a safer health system” (1999) • “Crossing the Quality Chasm” (2001) • “Patient Safety - Achieving a new standard for care” (2004) • 44,000 - 98,000 preventable deaths (estimated) • $29 Billion per year in additional costs

  3. “Little Progress Seen Since 1999 IOMReport On Medical Errors”…HealthGrades (2004)

  4. Why Do Errors Happen?

  5. Patient Safety Organization…

  6. Strategic / Policy Decisions Oversight Funding • Independent Agency/Board • Existing Agency • Licensure Board • General Funds • Assessment / Fees • Grant / Other Goal • Learning • Regulatory Charter • Statute • Regulation • Executive Order Patient SafetyOrganization

  7. Reporting Components Types of Events Who Reports Other Considerations • Acute Care Hospitals • Long-Term Care Facilities • Ambulatory Surgical Facilities • Free Standing Clinics • Pharmacies • Physician’s Offices • Other Licensed Entities By Definition • Medical Errors • Near Misses • Adverse Events • Serious Events Pre-Defined List • NQF “Never Events” • JCAHO Sentinel Events • Mandatory vs. Voluntary • Individual Identifying Data • Data Sharing • Confidentiality Provisions

  8. Pennsylvania’s Approach

  9. The Medical Care Availability and Reduction of Error (MCARE) Act of 2002 • Establishes the Patient Safety Authority • Goal: Reduce and eliminate medical errors by identifying problems and implementing solutions that promote patient safety • Promulgate new reporting requirements for: Hospitals, Ambulatory Surgical Facilities (ASF’s) and Birth Centers

  10. Patient Safety Authority • 11-member Board appointed by the Governor and General Assembly consisting of: • Physician General (Chair), Physician, Nurse, Pharmacist, Hospital employee, health care worker, non-health care worker, and 4 other PA residents • Established as an independent entity • Non-regulatory

  11. Funding Model • Allows for up to $5 Million a year. • Assessment of $105/unit based on: • For Hospitals: Licensed Beds • For ASFs: Licensed Operating Rooms • For Birth Centers: Licensed Birthing Rooms • In 2004 and 2005 – assessed $2.5 million or 50% of authorized amount.

  12. Reportable Events • Serious Event (“adverse event”) • Event that results in patient harm • Incident (“near-miss”) • Event that could have injured a patient • Infrastructure Failure • Event related to physical plant, facility systems and criminal activity

  13. PA - Reporting Components Types of Events Who Reports Other Considerations • Acute Care Hospitals • Long-Term Care Facilities • Ambulatory Surgical Facilities • Free Standing Clinics • Pharmacies • Physician’s Offices • Other Licensed Entities By Definition • Medical Errors • Near Misses • Adverse Events • Serious Events Pre-Defined List • NQF “Never Events” • JCAHO Sentinel Events • Mandatory vs. Voluntary • No Individual Identifying Data • Data Sharing • Confidentiality Provisions

  14. Reporting System

  15. Report Intake

  16. Report Intake • 21 Core Questions • Patient Age / Gender • Location • Event type • Level of harm, contributing factors and root causes • Recommendation to prevent future occurrence • Additional Event Detail Questions • 15 Major categories, 233 sub categories

  17. Patient Safety Authority - Clinical Analysis Incoming Reports Triage Patient Safety Review Meeting Analytics Program Outputs Public Advisories and Recommendations Contact with Individual Facilities PSA Annual Report

  18. Advisory Topics • Dangerous Abbreviation in Surgery • Falls Associated with Wheelchairs • MRI Hidden Risks • Hidden Sources of Latex • Use Of Multidose Medication Vials And Latex Allergy • Use of X-Rays for Incorrect Needle Counts • Preventing Wrong-Site Surgery

  19. Analytical Tools

  20. PA-PSRS Harm Score Trend

  21. PA-PSRS Distribution of Events 9% 11% 6% 9% 6% 16% 3% 21% 28% Slice 1 Slice 2 Slice 3 Slice 4

  22. PA-PSRS Event Distribution

  23. Event Details by Location

  24. Culture of Learning The ultimate success of this reporting system will not be found solely in the data collected. Rather, improved patient safety will be the result of actions taken by individual facilities in response to what they learn through PA-PSRS.

  25. PA Patient Safety Authority www.psa.state.pa.us

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