Pa Patient Saf Advis 2008 Mar;5(1):36.
Editorial: What is an Advisory?

John R. Clarke, MD, Editor
Pennsylvania Patient Safety Advisory


You will notice a new format for the Pennsylvania Patient Safety Advisory. Let me tell you why.

The Pennsylvania Patient Safety Reporting System (PA-PSRS) collects information about all medical errors in Pennsylvania, whether or not they harm patients. More importantly, its analysts try to identify lessons to be learned that will prevent others from repeating those errors. Sometimes, providers themselves identify and convey the lessons learned through the reports. Other times, the lessons only become apparent to analysts with large-scale aggregation of rare events. Always, the primary focus of the state’s patient safety reporting system is to share valid insights into the reliable delivery of appropriate, safe healthcare.

The primary vehicle for disseminating this information has been the PA-PSRS Patient Safety Advisory, colloquially know as the “Pennsylvania” Patient Safety Advisory. It is published quarterly with supplements when appropriate. The Advisory began, before full-scale reporting, with a four-page newsletter coinciding with Patient Safety Week in March 2004. Reporting brought information about how errors occurred and could be prevented and identified priorities for the errors that needed to be addressed. The result has been more than 140 original articles over the first four years. We have received about 500 reports of system changes per year from Pennsylvania facilities in response to these articles, including most notably, information about the wide variety of colors to convey information on wristbands, which led to standardization by a group of Pennsylvania Patient Safety Officers and ultimately an international convergence on colors for color-coded wristbands.

When conveying information to healthcare providers about improving ways to deliver healthcare, the analysts’ primary concern is that the information is unbiased, rational, and supported by the scientific evidence. Most of the information is based either on original analysis of the reports in the state patient safety database, currently containing nearly 700,000 reports, or on a comprehensive review of the literature. All articles conveying insights into improving the safe delivery of quality healthcare are reviewed by outside reviewers as part of the editing process. The editorial staff is grateful for the valuable contributions the reviewers provide.

The Advisory is disseminated electronically to all acute care facilities covered by Pennsylvania’s patient safety reporting requirement. It is also available to anyone through a free electronic subscription. The Advisory is currently received by more than 1,300 additional subscribers in 46 states and territories of the United States and 20 other countries, and it is indexed in the Cumulative Index to Nursing and Allied Health Literature (CINAHL).

With the first issue of 2008, you will see a new format. In addition to matching our official name to our commonly used name, we have reserved the cover for the Table of Contents. To help you, we have added a one-line description of each scientific article. Each scientific article will also begin with an abstract to summarize the article for the benefit of you, the reader.

We are also pleased to have added an editorial advisory board to assist us in obtaining outside reviews of our scientific articles and to provide broader oversight for the quality of the Advisory (beyond our current surveys of Patient Safety Officers in Pennsylvania). We are indebted to them for their willingness to contribute.

We plan to continue our invited articles on leadership, our interest in publishing letters to the editor when we receive them, and our self-assessment questions to measure retention.

As always, we welcome input and feedback. Mechanisms for communicating information to the editor can be found on the expanded masthead between the cover and the lead article. We hope you find the new format an improvement in the delivery of information about safe healthcare practices.


The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed.

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