Patient Safety Authority Releases Actionable Insights

Harrisburg, PA – June 15, 2020 -- The Patient Safety Authority (PSA) has released its 2019 annual report, offering key insights to inspire change and improve patient safety in Pennsylvania and beyond. The conclusions are based on information from the Pennsylvania Patient Reporting System (PA-PSRS), the largest repository of patient safety data in the United States and one of the largest in the world with 4 million event reports.
“Inspiring action through research is at the core of our work,” said Regina Hoffman, executive director of the PSA. “Among the main issues for action are newborn falls, telemetry monitoring, medication errors, and improving diagnoses.”

  • Newborn falls most often occur in healthcare facilities because the caregiver falls asleep, the data shows. Hospitals should support new mothers and fathers in the hours and days following birth, and round more frequently when new mothers are breastfeeding.

  • The patient harm associated with telemetry monitoring is rare but potentially catastrophic. Healthcare facilities should focus on processes for continuous monitoring, daily care of equipment, and on communication between frontline clinicians and biomedical and clinical engineering staff.

  • With medication errors involving infusion pumps, the key contributing factors that need to be addressed are tubing/connections, pump programming, and pre-administration processes.

  • Through its Center of Excellence for Improving Diagnosis (CoE), the PSA found that there is a lack of systemic effort to improve diagnostic processes within and across healthcare facilities. The PSA is working on a novel, comprehensive assessment tool to identify facility-specific gaps and set priorities.

The annual report also highlights patients’ important role in academic publishing. In 2019, the PSA launched Patient Safety, a quarterly, peer-reviewed journal of original scientific research and patient commentaries to advise healthcare systems, providers and frontline staff. The first two issues were read by more than 15,000 people across every state in the United States and in 139 countries, increasing global reach over its previous publication by more than 200 percent.
In conjunction with the Annual Report, the PSA released figures from the PA-PSRS. Event reporting grew by 3.2%, continuing an increase in reporting rates each year that may reflect improvements in patient safety culture across the Commonwealth.

Established under the Medical Care Availability and Reduction of Error (MCARE) Act of 2002, the PSA, an independent state agency, collects and analyzes patient safety data to improve safety outcomes and help prevent patient harm.  http://patientsafety.pa.gov/

©2020 Pennsylvania Patient Safety Authority