The breadth, depth, and scope of patient safety education programs sponsored by the Pennsylvania Patient Safety Authority are designed to meet the needs of their audiences, including all key stakeholders who have an interest in seeking knowledge that can be applied to enhance patient safety in the delivery of healthcare. Therefore, the programs encompass material that is geared toward those in a variety of roles and responsibilities, from frontline staff to clinicians to executive leadership.
The initial point of contact for integration of learning has historically been those healthcare personnel whose title specifically identifies them as the person spearheading the patient safety program within their respective healthcare organization. The very first offering of the Patient Safety Liaison program was in early 2009 and included basic patient safety education to 15 patient safety officers (PSOs). The full-day curriculum, called Patient Safety Officer Basics, covered the key elements contained in chapters 3 and 4 of the Medical Care Availability and Reduction of Error (Mcare) Act, the role and responsibility of the PSO, the framework and components of a patient safety infrastructure, recognition of patient safety challenges, and identification of key terms associated with patient safety. Later that year, a sequel program called Beyond the Basics was offered. This two-day program allowed attendees to apply learned concepts using simulation, role-play, and group work. Content covered key patient safety concepts and methods such as human factors, human error, root-cause analysis, failure mode and effects analysis, patient disclosure, teamwork and communication, and measuring patient safety.
Today, the Authority is reaching a wider audience with more in-depth education on a variety of patient safety concepts (see the Table). The Authority has expanded from offering an educational event in Pennsylvania every 3 days to every 1.5 days. Education topics include but are not limited to the importance of event reporting, human factors, just culture, TeamSTEPPS, organizational patient safety and patient engagement, identifying and managing risk, disclosure, and achieving and sustaining change. During fiscal year 2012-2013, the Authority educated an average of 18.5 individuals per workday. The Authority continues to offer the Patient Safety Officer Basics and Beyond the Basics courses, but the programs have fundamentally grown to meet the increased educational demands of PSOs, their delegates, and other key stakeholders who have expressed interest in learning more about patient safety.
Type of Event||
No. of Events||
|Ambulatory surgical facility healthcare-associated infection workshops||Regional ||4||200||50|
|Networking ||Regional ||11||261||24 |
|Patient Safety Officer Basics||Regional||2||107||54|
|Patient Safety Officer Beyond the Basics||Regional ||2||92||46|
|Patient Safety You Design*||Statewide||4||138||35|
|Quality Curriculum for Trustees||Facility-specific||2||69||35|
* Half-day programs with a more in-depth review of just culture, teamwork and communication, measures and metrics in patient safety, or root-cause analysis.
† One-hour programs on topics such as human factors, why reporting matters, teamwork and communication, culture of safety, just culture, methicillin-resistant
Staphylococcus aureus, falls prevention, and operating room fire safety.
Within the last fiscal year (2012-2013), the Authority offered a statewide program to hospitals, ambulatory surgical facilities, abortion facilities, and birthing centers that included four half-day sessions. It was called Patient Safety You Design. Topics included enhancing teamwork and communication, implementing a just culture model, conducting root-cause analysis in healthcare, and using data for patient safety. Participants included PSOs, quality directors, risk managers, human resources personnel, and other healthcare leaders. All sessions provided a more in-depth review of the topic and its application to healthcare. Participants learned from group activities and exercises using case studies.
Since the publication of the Institute of Medicine’s
To Err Is Human: Building a Safer Health System, there has been a heightened awareness of the magnitude of medical errors and the urgent need to respond. Programs offered by the Authority provide foundational concepts of patient safety and a base for stakeholders to learn more about how the application of key principles can influence a culture that supports and promote patient safety. It is a transformative journey that moves from a culture of blame and shame, communication silos, hiding errors, workarounds, and business as usual toward a culture of teamwork and communication, just and fair culture, patient centeredness, and transparency. Programs are geared toward achieving active learning and high reliability. Since the inception of the Authority’s educational programs and continuing to this day, these key elements have been a mainstay of patient safety curriculums.
Recognizing that healthcare workers have multiple demands and time constraints, the Authority understands that it is sometimes difficult to attend in-person sessions. With this in mind, other platforms have been explored to offer programs that individuals can access remotely through the use of our patient safety webinars. In 2013, statewide webinar topics included falls prevention, infection prevention in long-term care, safety for bariatric patients, operating room fire safety, and anesthesia time-outs. Webinars averaged more than 200 attendees per session, and attendees represented multiple disciplines from reporting facility settings (nursing homes, hospitals, ambulatory surgical facilities, abortion facilities, and birthing centers). The Authority will continue to strive to offer these programs at least monthly, if not more often, in response to facility feedback.
The Authority recognizes that learning can be accomplished on a variety of platforms. Webinars meet the learning needs of those unable to attend in-person sessions. However, in-person programs have added value because of face-to-face interactions and the networking that take place among attendees. With this in mind, the Authority continues to offer regional networking sessions and encourage participants to share their wisdom and/or lessons learned in the field. The platform also provides an opportunity for education.
The western regional session has a one-hour educational program called Author in the Room in which Authority staff offer didactic presentations on recent
Pennsylvania Patient Safety
Advisory articles and entertain questions from the audience. Outside of this one-hour educational session, attendees are given the opportunity to openly share and talk about items of interest. These could be conversations about things like recently released standards or regulations and/or how facilities are addressing certain patient safety topics, issues, or barriers within their organization. It is an opportunity for collective sharing, lessons learned, and ideas for new approaches to patient safety issues.
Facility-specific programs are also offered based on requests and/or identified needs. The Authority either develops new topic content or customizes existing topic content in response to facility requests. Some of the existing educational programs provided to healthcare workers have focused on foundational concepts in patient safety or clinically specific topics such as infection prevention, prevention of wrong-site surgery, falls prevention, medication safety, fire safety in the operating room, and others. The Authority also has master trainers who can assist facilities in conducting TeamSTEPPS train-the-trainer programs, as well as staff who are certified in just culture training.
Typically, these programs are geared toward the healthcare worker, clinician, or executive leadership. However, there are some programs offered to patient groups (e.g., senior citizen programs, children’s hospital programs). Consumer tips and other pertinent patient safety information are made available to public consumer groups through patient safety fairs and educational programs.
Collective feedback from certain facility types has also generated patient safety programs focused on topics of interest. In response to both formal and informal survey activities with ambulatory surgical facilities, the Authority has offered a succession of programs over the past few years that have focused attention on infection prevention. In 2013, there were 200 ambulatory surgical facility participants who attended four regional, full-day workshops in which infection prevention analysts shared information about safe injection practices, disinfection and sterilization, and overall general infection prevention information.
Clinically oriented students are also key stakeholders in the future delivery of healthcare. Medical and nursing educational programs train students as individuals; yet, as practitioners, they must work in teams within healthcare organizations. Authority-sponsored programs teach the value of teamwork and communication using the TeamSTEPPS model. This is a teamwork program developed by the US Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality that has been scientifically rooted in 20 years of research and lessons from the application of teamwork principles. It has been shown to produce highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients. It is a powerful solution to improving patient safety within healthcare organizations.
With patient safety and quality being a key focus of healthcare facilities, there is an ever-increasing demand for boards to have an active role in inspiring even greater performance. The Authority has partnered with other organizations—for example, the Hospital and Healthsystem Association of Pennsylvania and American Hospital Association’s Center for Healthcare Governance—to offer a curriculum encompassing interactive learning modules on mission, culture, performance, leadership, strategy, and resources.
The Authority continues to customize programs in order to meet the needs of varying audiences, from board members to frontline staff to patients. Consumer feedback that is received from formal program evaluations, annual survey responses, and other verbalized input is used in program development and planning. It is an important component in evaluating the value of the programs and provides direction for future development of patient safety education.
Further, in order to recognize the participant’s commitment to patient safety and provide evidence of their attendance at varied programs, the Authority offers certificates of attendance for Authority-sponsored educational programs. Some national, state, and local licensing boards and professional organizations will grant continuing education credits for attendance when the course outline and certificate of attendance are submitted. Each attendee is encouraged to contact their practice board or organization to find out what is required and if the educational offering meets those requirements.
Making healthcare safer is the challenge for all those working in this industry. It is a complex system made of multiple disciplines providing patient care in a world that is constantly adapting to changes, including complex technology, powerful drugs, and new devices. At its heart are humans providing care to humans. The Authority has learned over the last decade that adverse events overwhelmingly occur not because bad people intentionally hurt patients but rather because the system of healthcare today is so complex that the successful treatment and outcome for each patient depends on a range of factors, not just the competence of an individual healthcare provider. With this knowledge, healthcare systems are challenged to mitigate the risk of patient harm due to medical errors.
Programs to enhance knowledge surrounding patient safety provide the learner with the tools to make effective changes and reduce the likelihood of adverse events. Topic development and offerings are generated in response to the audience needs. Therefore, input and feedback from those attending Authority programs through the use of post-evaluation surveys and completion of annual Authority surveys are strongly encouraged. Updates and information about Authority educational program offerings can be accessed by PSOs and their delegates on the calendar of the Patient Safety Knowledge Exchange website or by contacting the Authority directly at (717) 346-0469 or at patientsafety.pa.gov. Full Authority contact information is listed at http://patientsafety.pa.gov/PatientSafetyAuthority/Pages/PSAStaff.aspx.