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The Board of Directors has 11 members: a physician appointed by the Governor who serves as Board chair; six other members appointed by the Governor to fill seats designated for specific professional occupations; and four members appointed by the General Assembly.
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2016 Pennsylvania Patient Safety Authority Annual Report
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PSRS Data Interface
Each facility should complete and return the attached form designating its primary contact for information related to patient safety.
PA-PSRS Data Interface Schema 6.5 changes
PA-PSRS Data Interface Schema Changes history
Nearly 900 medication error reports listed health information technology (HIT) as a factor contributing to the event submitted to the Pennsylvania Patient Safety Authority. The most common HIT systems implicated in the events were the computerized prescriber order entry system, the pharmacy system, and the electronic medication administration record.
Hospitals can decrease the risk for gastrointestinal tube complications by implementing best practices and risk reduction strategies to confirm proper positioning of gastrostomy tubes and to prevent, recognize, and manage dislodgement. Aside from peritonitis, sepsis, and death, other serious harm can result from even minor changes in gastrostomy tube position.
Handoffs are an integral part of care coordination and the delivery of safe patient care. Using handoff processes that incorporate critical thinking and reasoning skills to address patient needs and providing handoff training and education are strategies to improve patient handoff communications.
Surgical items such as sponges, sharps, and instruments may be retained during surgery and can lead to serious patient harm. Detecting and reporting retained surgical items may help to determine patterns and root causes using a definition decided upon by the healthcare facility.
Influenza is a contagious respiratory illness that can cause mild to severe illness and can lead to death. Long-term care facilities can promote influenza vaccination each season by reducing barriers to healthcare personnel vaccination.
The Pennsylvania Patient Safety Authority’s annual I Am Patient Safety contest promotes individuals and groups within Pennsylvania’s healthcare facilities who have demonstrated an exceptional commitment to patient safety. The Authority congratulates the individuals recognized for their efforts to improve patient safety in Pennsylvania’s healthcare facilities, and applauds their commitment.
The challenge in managing the potential for data overload is to determine the ideal middle ground between excessive data and insufficient information and to arrange the relevant information in a manner that supports clinicians’ cognitive processes.
This recurring feature highlights successes of healthcare workers in keeping patients safe; in this instance, an experienced nurse catching a near 10-fold overdose of medication.
This is the table of contents for the March 2017 Pennsylvania Patient Safety Advisory
Healthcare facilities can help reduce the opportunity for drug interactions reaching patients by addressing all areas of the medication-use process and not relying solely on the effectiveness of alerts when orders are entered into electronic health records.
Fostering an environment that supports effective patient safety programs is inherent to the Authority’s mission. A select set of patient safety measures were chosen to demonstrate the results of the combined efforts of Pennsylvania healthcare facilities, statewide quality improvement entities, and the Authority to improve patient safety.
Discharge is a critical transition period for patients and a process that calls for education, assessment, follow-up, organization, confirmation, and review.
The survey results from the national project revealed that the tools were valuable to the majority of respondents by improving catheter-associated urinary tract infection (CAUTI) identification, process and outcome measurement, CAUTI case root-cause analysis, and CAUTI prevention and control measures.
Accidental injection of oral nimodipine for patients unable to swallow may result in severe hypotension, cardiovascular collapse, or cardiac arrest.
Analysis of wrong-site events reported by ambulatory surgical facilities identified an increase in these reported events over time.
An online educational program, "Get the Facts on Toxic Anterior Segment Syndrome," is available about the etiology of and care and treatment for TASS.
A request to update data from an 2009 article led Pennsylvania Patient Safety Authority analysts to query the reporting database for maternal events. The most common maternal Serious Events reported are laceration of the birth canal, postpartum hemorrhage, and bladder laceration.
In the December 2006 PA-PSRS Patient Safety Advisory, a sentence in the article “Bone Cement Implantation Syndrome” omitted a key phrase.
Reporting unsafe conditions identified during simulation to the Pennsylvania Patient Safety Authority may expand knowledge and advance patient safety.
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Patients should learn about the symptoms of Clostridium difficile infection and be aware of the association between these symptoms and recent antibiotic therapy.
The Pennsylvania Patient Safety Authority is an independent state agency created to help reduce and eliminate medical errors.
It is important for patients to protect themselves as much as they can from getting an infection such as MRSA.
Patients who do know their full medical history are at increased risk to receive unecessary surgery or medical care.
There are steps that patients can take to prevent falls in the healthcare facility and at home.
Discharge is a critical transition period for patients. Potential problems for patients could include leaving without discharge instructions, leaving with incomplete discharge instructions, or leaving with another patient's discharge instructions.
Medication errors are one of the most common types of medical mistakes; however, there are steps patients can take to protect themselves in healthcare settings, at the pharmacy, and at home.
Many factors must be determined before a patient considers ending a wanted pregnancy after receiving an x-ray while unaware of a pregnancy.
Screening Tool helps patients determine whether or not they have sleep apnea
Wrong-site surgeries are 100 percent preventable, and patients or their family members can help prevent such errors by speaking up.
Healthcare facilities use color-coded wristbands to communicate important medical information; patients can take certain steps to ensure that nonmedical wristbands are not misunderstood.
The Authority data shows healthcare providers and patients do not fully understand the differences between a living will and DNR orders
Patient Screening and Assessment in Ambulatory Surgical Facilities
In 2008, the Pennsylvania Patient Safety Authority received about 150 reports describing events in which patients with certain implanted objects or in which patients were not screened properly for metallic items were scheduled for MRI scans.
Patients who are in the hospital often may ask a loved one to bring them some food or a milkshake to make them feel better. The Patient Safety Authority has received reports that show patients have died from choking because family members have given their loved ones food when the patient was not supposed to have it.
Flu and pneumonia are significant causes of death from vaccine-preventable diseases, with 90 percent of these deaths occurring in adults age 65 or older, including those residing in long-term care facilities.
Flu and pneumonia are significant causes of death from vaccine-preventable diseases, with 90 percent of these deaths occurring in adults age 65 or older.
The Pennsylvania Patient Safety Authority received over 316 reports of babies who experienced getting their shoulder stuck (known as shoulder dystocia) in the birth canal during delivery.

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