PA PSRS Patient Saf Advis 2005 Jun;2(2):1-2.  
Patient Safety Authority Update

Alan B. K. Rabinowitz
Patient Safety Authority


This month marks the one year anniversary of the PA-PSRS system, a significant milestone in patient safety for Pennsylvania’s healthcare providers and patients alike.

While we will have received more than 150,000 reports by the time this Advisory goes to print, numbers alone are not the measure of PA-PSRS’s success. That measure is the result of how facilities use PA-PSRS and how they respond to Act 13’s other patient safety requirements.

In a recent conversation, the vice president for medical affairs at a hospital in Central Pennsylvania spoke enthusiastically about how Act 13 and the PA-PSRS reporting system raised patient safety to the forefront within his facility.  He described how they considered patient safety in designing a new wing and how mandatory reporting has enhanced communications between different segments of the staff. PA-PSRS, he recounted, has increased physician awareness of process issues and is encouraging nurses to speak out more freely. In summary, he concluded that PA-PSRS has both focused his organization’s attention on patient safety and actually increased patient safety within his facility.

These are not isolated comments. In a recent news story carried in publications targeted to the physician community, several hospital executives cited examples where PA-PSRS has facilitated clinical improvements and other positive outcomes within their organizations. For example, a critical access hospital streamlined its patient transfer process based on the results of a root cause analysis conducted after a PA-PSRS report submission. A large academic medical center reported making changes within its operating rooms as a result of a recent Patient Safety Advisory article. And a community hospital attributed a reduction in medication errors to use of the PA-PSRS analytical tools, singling out the usefulness of being required to answer questions related to so-called “contributing factors” on the PA-PSRS reporting form.

While each of the above-cited facilities focuses on different aspects of PA-PSRS, their examples validate the system’s usefulness and the benefits of a mandatory reporting system based on a culture of learning. This issue of the Patient Safety Advisory, the eighth since we initiated publication last year, is an integral component of the Authority’s commitment to promote patient safety by sharing knowledge and best practices. As one hospital executive noted, Advisory articles are inherently practical because they are derived from actual events in Pennsylvania institutions, whereas many academic articles about patient safety have little immediate clinical relevance.

We hope that you are finding PA-PSRS beneficial in enhancing patient safety efforts and promoting a culture of safety within your facility. We encourage you to share your experiences with us so we, in turn, can share them with others.


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