Pa Patient Saf Advis 2013 Dec;10(4):146-9.
A Decade of Dedication to Improvement


John R. Clarke, MD
Editor Emeritus, Pennsylvania Patient Safety Advisory
Clinical Director, Pennsylvania Patient Safety Authority
Professor of Surgery, Drexel University


This issue of the quarterly Pennsylvania Patient Safety Advisory (vol. 10, no. 4) completes the first decade of presenting the reviews and analyses of reports from the Pennsylvania Patient Safety Reporting System (PA-PSRS). During this first decade of publication, the Pennsylvania Patient Safety Authority has published more than 440 articles in 40 quarterly issues and 12 supplementary issues, starting with a four-page Advisory in March 2004. That inaugural issue contained information about the Authority, Patient Safety Awareness Week, and four clinical topics motivated by pilot reports from PA-PSRS: potentially dangerous abbreviation in surgery, fall narratives, falls associated with wheelchairs, and hidden risks with magnetic resonance imaging.1

Early issues of the Advisory were characterized by advice to providers, such as “risks can be reduced by using wheel locks.”1 Over time, the Authority noticed that Advisory issues were followed by a transient decrease in event reports—or occasionally an increase in reports as providers became aware of the problem2 or recognized the value of reporting the problem—followed by a return of the reported events as providers’ extra vigilance waned. Checklists, algorithms, and other decision aids were added to the Advisory to augment the efforts to educate providers—for example, an algorithm to identify patients at risk for contrast-induced nephropathy.3

Occasionally, the Authority noticed a sustainable effect. For instance, a supplementary Advisory on insulin overdoses due to confusion between similarly packaged insulin and tuberculin syringes4 produced system changes within facilities.5 This observation led the Authority to focus the Advisory on providing actionable information to patient safety committees and system managers, rather than providers, with enough information for providers to establish a need for system change. It was satisfying, for instance, to hear a patient safety officer relate that members of the patient safety committee compared the facility’s policy for healthcare industry representatives in the operating rooms with the elements listed in an Advisory article on that subject.6

Even more satisfying was the response of facilities to a single near-miss incident involving confusion about the meaning of a color-coded patient wristband.7 Because the single report did not provide enough information to offer solutions, the Authority conducted a focused follow-up survey to better understand the problem. One hundred thirty-nine facilities responded with a kaleidoscope of colors and meanings. This information prompted a group of 11 facilities in Pennsylvania, chaired by Bonnie Haluska of Allied Services Rehabilitation Hospital, to collaborate on standardizing color codes and the information they should convey.8 This information was subsequently used by the American Hospital Association to standardize color-coded wristbands nationally.9

Aggregation of reports from all facilities in the commonwealth affords the Authority the luxury of analyzing many instances of an event, especially a rare event that no one facility might see more than once, such as surgical fires,10 and identifying multiple weaknesses that can result in an adverse outcome. The emphasis of the Advisory staff is on identifying each way a system fails, which is usually more useful than identifying each time a system fails. A comprehensive review of all the failure modes leads to a comprehensive critique of the system for delivering care, resulting in advice for making the entire system more robust, not just correcting the one weakness associated with a single event. This approach has allowed the Authority to develop meaningful strategies without worrying about whether the number of events reported or the number of situations at risk for such an event is accurate.

As facilities tried to implement system changes and educate their hospital and physician staffs about the need for change and the choices for safe practices, they found that physicians wanted scientific evidence that the changes would represent improvements. These sentiments were conveyed to the Authority and prompted the Advisory staff to develop and disseminate the evidence supporting safe practices. Collecting sufficient scientific evidence required more than counting relevant event reports and recounting their patterns and their narratives in a contextually deidentified manner. Once a topic was selected, based on novelty, frequency and severity, and the potential for improvement, the Authority sought supplemental information from the facilities, which many facilities readily contributed in an effort to provide themselves and others with a deeper understanding of the relationship between processes and outcomes.

One example of cooperation by facilities has been the willingness to standardize facility criteria for reporting a specific event, such as falls,11 so that comparisons can reliably be made across multiple, unrelated facilities.

The ongoing project to prevent wrong-site surgery is another excellent example of the magnitude of the cooperation by facilities with the techniques the patient safety analysts have used to develop scientific evidence to identify and support safe practices. Facilities have cooperated by letting patient safety analysts observe their processes12 and by completing questionnaires about their experiences.13

Most importantly, facilities have cooperated by submitting information about their policies,14 recording their compliance with policies,15,16 and using a common form for root-cause analyses of both near-miss and actual wrong-site surgery events.17 The willingness of facilities to provide additional specific information in follow-up to their initial near-miss and wrong-site surgery reports helped the Authority to identify processes that differed when comparing groups with wrong-site surgery to those without. The Authority ultimately identified 21 evidence-based best practices for the processes related to performing the Universal Protocol to effectively prevent wrong-site surgery.16 Getting sufficient information to identify patterns and differences in patterns between groups with different outcomes has proven critical to establishing the evidence base for safe practices in the delivery of healthcare.

The Advisory staff made a commitment at the onset of the project to prevent wrong-site surgery in 2007. The commitment was not the obvious: to follow up on the success of the project at some time in the future. The commitment was to report on the impact of the project in every quarterly issue. This self-induced challenge seemed embarrassing as quarter after quarter produced the same number of reports. But this obvious lack of progress added an urgency to the realization that identifying and presenting evidence-based best practices, although necessary to create change, were not sufficient to successfully disseminate and implement those best practices and systematically reduce errors.

Recognizing the need to effectively disseminate the evidence-based best practices published in the Advisory, the Authority appointed a director of educational programs, Franchesca Charney, to develop and implement educational opportunities for healthcare providers to learn collectively within their facilities and across facilities.18 The Authority developed a team of patient safety liaisons, now eight, to provide a presence in facilities, working with each facility individually to overcome any obstacles it may be having in implementing evidence-based safe practices.19

The Advisory staff noted some successes in individual facilities when leadership was engaged and supportive and when frontline staff were involved in and had a sense of owning a system redesign—“commitment from the top down; process from the bottom up.”20

To facilitate learning collectively and collaboratively, the Authority developed a secure website, PassKey (Patient Safety Knowledge Exchange), that allows facilities to share information within the confidentiality confines of the Authority.21

With the knowledge of a prior successful collaboration,8 the lessons learned for successful implementation in individual facilities,20 the PassKey infrastructure for collaborations,21 and interest expressed by facilities to patient safety liaisons about working collaboratively with other facilities,22 the Authority considered a collaborative learning model: facilities learning from each other how to identify and overcome barriers and redesign systems to successfully implement evidence-based best practices.23

In the spring of 2008, the Authority accepted an offer from the Health Care Improvement Foundation’s Partnership for Patient Care to develop a collaborative learning model for preventing wrong-site surgery. The program used the principles of educating providers about evidence-based best practices, identifying gaps in policies and compliance, and collectively discussing systems to implement best practice and strategies to overcome barriers to implementation.24 In follow-up meetings, the 30 facilities in the collaboration discussed successes and failures in implementing system redesigns and overcoming barriers.24 The collaborative learning model proved successful for implementing evidence-based best practices15 and was successfully replicated in a second initiative to prevent wrong-site surgery.16

The collaborative learning model has proven generalizable. The Authority has now also experienced success in using collaborative learning with volunteer facilities to improve the accuracy of blood specimen labeling23,25 and the rates of falls with harm.26

Unfortunately, either a commitment of leadership to a system redesign to implement best practices or collaborative learning is as necessary as the evidence-based best practices to successfully reduce errors. As an example, all the improvements in preventing wrong-site surgery have occurred in the facilities that had the commitment of leadership and/or participated in collaborative learning to implement best practices. The other facilities in Pennsylvania have actually shown an increase in wrong-site surgeries.27

Having achieved successes with identifying evidence-based best practices and overcoming barriers to implement them, with good compliance, the Authority is beginning to address the sustainability of the compliance.28

Broader challenges still need attention, such as changing cultures, developing effective teamwork,29 establishing reliable methods of communicating information,30,31 and minimizing diagnostic errors.32

Do reporting and analyzing medical errors, both near-miss “Incidents” and adverse “Serious Events,” and disseminating evidence-based best practices for providing reliable care produce value for the healthcare system? Documentation that these activities directly result in improvement in health outcomes is speculative, despite aforementioned success stories noted in this journey (e.g., collaborations), but providers should be pleased to see that improvement has occurred during the decade. Following passage of the enabling Medical Care Availability and Reduction of Error Act,33 medical malpractice claims have dropped from a peak of 701 in 2003 to 329 in 2010, with a decrease in payments from $378,700,000 to $146,500,000 over the same period.34

Compared with that first modest issue,1 the Advisory has grown and changed over the past 10 years. The Advisory is now a peer-reviewed, open-access, online journal with a large, diverse, and representative editorial advisory board. It is indexed in the National Library of Medicine Catalog and the Cumulative Index to Nursing and Allied Health Literature (CINAHL® Plus). The Advisory is currently distributed to more than 4,650 healthcare providers in Pennsylvania and over 4,000 additional subscribers in all 50 states and 37 other countries. Many Advisory articles are accompanied by learning objectives and self-assessment questions and are subsequently associated with continuing medical education credits or nursing continuing education credits from the Pennsylvania Medical Society and Pennsylvania State Nurses Association, respectively.

Hopefully, the Advisory will continue to change as the sciences of analyzing patient safety events and implementing safe practices mature.

One other change has already happened. After 10 years as editor and turning 70, I have stepped down to make room for the next generation. You will note on the masthead that I am now editor emeritus and that Karen P. Zimmer, MD, MPH, is acting editor. I will continue to contribute to the Advisory, especially the wrong-site surgery updates, but take this opportunity to give thanks for the support of the publisher of the Advisory, the Authority; past and current members of Authority’s board of directors; the Authority’s staff under the leadership of Michael Doering and Franchesca Charney; and Thomas Ignudo and his Hewlett-Packard team supporting PA-PSRS. I also thank the members of the editorial advisory board, who have provided many helpful suggestions; the many experts who have provided peer review of the Advisory before publication; and the patient safety officers at the facilities, many of whom have become my friends while showing commitment to the patient safety effort by making the extra effort to provide supplemental information. I am very grateful for the privilege of working with the past and current staff at ECRI Institute and the Institute for Safe Medication Practices, who produce the Advisory under contract to the Authority. In particular, I must thank the Advisory’s support staff and all the patient safety analysts over the years who have done the hard work of reviewing and analyzing the patient safety reports with the leadership of Theresa Arnold, DPM, and William Marella; the data analyst, Edward Finley, who finds needles in the haystack on a daily basis; our coordinator Miranda Minetti, who keeps me pointed in the right direction; and the linchpin of the Advisory, Jesse Munn, the very patient managing editor.


  1. Pennsylvania Patient Safety Authority. Patient safety week advisory [online]. 2004 Mar [cited 2013 Oct 24].
  2. Forgotten but not gone: tourniquets left on patients. PA PSRS Patient Saf Advis [online] 2005 Jun [cited 2013 Oct 24].
  3. Pennsylvania Patient Safety Authority. Management of patients undergoing iodinated contrast-related procedures [online]. 2007 [cited 2013 Oct 24].
  4. Overdoses caused by confusion between insulin and tuberculin syringes. PA PSRS Patient Saf Advis [online] 2004 Oct 28 [cited 2013 Oct 24].
  5. Follow-up on previous Advisory articles. PA PSRS Patient Saf Advis [online]. 2004 Dec [cited 2013 Oct 24].
  6. Healthcare-industry representatives: maximizing benefits and reducing risks. PA PSRS Patient Saf Advis [online] 2006 Mar [cited 2013 Oct 24].
  7. Use of color-coded patient wristbands creates unnecessary risk. PA PSRS Patient Saf Advis [online] 2005 Dec [cited 2013 Oct 24].
  8. Pennsylvania Patient Safety Authority. The color of safety [online]. [cited 2013 Oct 24].
  9. American Hospital Association. Implementing standardized colors for patient alert wristbands [online]. 2008 Sep 4 [cited 2013 Oct 24].
  10. Clarke JR, Bruley ME. Surgical fires: trends associated with prevention efforts. Pa Patient Saf Advis [online] 2012 Dec [cited 2013 Oct 24].
  11. Gardner LA. Standardizing reporting of patient falls: a survey of Pennsylvania hospitals. Pa Patient Saf Advis [online] 2012 Jun [cited 2013 Oct 24].
  12. Insight into preventing wrong-site surgery. PA PSRS Patient Saf Advis [online] 2007 Dec [cited 2013 Oct 24].
  13. Improvement in preventing wrong-site surgery! Traction or transient? Pa Patient Saf Advis [online] 2009 Sep [cited 2013 Oct 24].
  14. Quarterly update on the preventing wrong-site surgery project. PA PSRS Patient Saf Advis [online] 2008 Jun [cited 2013 Oct 24].
  15. Pelczarski KM, Braun PA, Young E. Hospitals collaborate to prevent wrong-site surgery. Patient Saf Qual Health 2010 Sep-Oct:20-6.
  16. Pennsylvania Patient Safety Authority. The evidence base for the principles for reliable performance of the Universal Protocol [online]. 2012 [cited 2013 Oct 24].
  17. Blanco M, Clarke JR, Martindell D. Wrong site surgery near misses and actual occurrences. AORN J 2009;90(2):215-22.
  18. Pennsylvania Patient Safety Authority. Pennsylvania Patient Safety Authority hires director of educational programs [press release online]. 2008 Oct 30 [cited 2013 Oct 24].
  19. Pennsylvania Patient Safety Authority. Pennsylvania Patient Safety Authority hires patient safety liaison to help healthcare facilities implement guidance [press release online]. 2008 Aug 28 [cited 2013 Oct 24].
  20. Quarterly update on the preventing wrong-site surgery project. Pa Patient Saf Advis [online] 2010 Jun [cited 2013 Oct 24].
  21. Pennsylvania Patient Safety Authority. PassKey (Patient Safety Knowledge Exchange) [online]. [cited 2013 Oct 24].
  22. Shetterly M. Collaborative patient safety effort: addressing phlebotomy specimen mislabeling. Pa Patient Saf Advis [online] 2009 Sep [cited 2013 Oct 24].
  23. Clarke JR. Editorial: the value of collaborative learning for disseminating best healthcare delivery practices. Pa Patient Saf Advis [online] 2011 Jun [cited 2013 Oct 24].
  24. Clarke JR. What keeps facilities from implementing best practices to prevent wrong-site surgery? Barriers and strategies for overcoming them. Pa Patient Saf Advis [online] 2012 Nov [cited 2013 Oct 24].
  25. Reducing errors in blood specimen labeling: a multihospital initiative. Pa Patient Saf Advis [online] 2011 Jun [cited 2013 Oct 24].
  26. Arnold TV, Barger DM. Falls rates improved in southeastern Pennsylvania: the impact of a regional initiative to standardize falls reporting. Pa Patient Saf Advis [online] 2012 Jun [cited 2013 Oct 24].
  27. Clarke JR. Quarterly update on preventing wrong-site surgery. Pa Patient Saf Advis [online] 2012 Mar [cited 2013 Oct 24].
  28. Clarke JR. Quarterly update on wrong-site surgery: trying to hold the gains. Pa Patient Saf Advis [online] 2013 Jun [cited 2013 Oct 24].
  29. Supplement 2 [volume 7]. Pa Patient Saf Advis [online] 2010 Jun [cited 2013 Oct 24].
  30. Safe patient outcomes occur with timely, standardized communication of critical values. Pa Patient Saf Advis [online] 2009 Sep [cited 2013 Oct 24].
  31. Communication of radiograph discrepancies between radiology and emergency departments. Pa Patient Saf Advis [online] 2010 Mar [cited 2013 Oct 24].
  32. Diagnostic error in acute care. Pa Patient Saf Advis [online] 2010 Sep [cited 2013 Oct 24].
  33. Medical Care Availability and Reduction of Error (Mcare) Act, 2002 Pa. Laws 154, No. 13. Also available at
  34. Marella WM. Commentary: signs of safety improvement in Pennsylvania’s healthcare community. Pa Patient Saf Advis [online] 2011 Mar [cited 2013 Oct 24].

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