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Destination Pennsylvania: Where Patient Safety is Purposefully Different and What You Need to Know About It

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​In a September 2020 press release​, the American College of Healthcare Executives reported a 17% CEO turnover rate in 2019. That is a lot of executives leaving their positions and taking up new posts or retiring as someone new fills their shoes. With only a handful of states having more licensed hospitals than Pennsylvania, chances are many of these movers and shakers will spend some time in a Keystone corner office.​

As the new C-suite member, you sit down for your first one-on-one meeting with the patient safety officer and they tell you that your facility had almost 300 reportable events last month and 10 patients received disclosure letters for events that were serious. Does your stomach flip? Do you wonder what kind of special hell you just walked into? I imagine that might be how you feel until you understand why patient safety is different in Pennsylvania than in all your former locales.​​​

  1. ​​The Patient Safety Authority (PSA) is uniquely positioned in state government to help your facility improve patient safety. PSA is funded directly by healthcare facilities and is governed by an independent board. It is nonpunitive and serves as your partner in patient safety.

    ​​​​​PSA staff provide education; individualized consultation; toolkits; and Patient Safety, a quarterly peer-reviewed publication featuring the latest information from its database, expert interviews, patient perspectives, and other research.​


    No other state in the country offers the patient safety resources that Pennsylvania offers.


  2. ​​​​​There is no additional charge for the services PSA provides to your facility—you already pay for them in your legislated annual assessment. Furthermore, because you participate in the mandated reporting requirements, your facility is not required to join ​a Patient Safety Organization—saving you money and duplicate effort. PSA provides confirmation letters of your participation ​upon request.
  3. ​Pennsylvania has the largest event reporting database of its kind in the country and one of the largest in the world—because healthcare facilities are required to report everything. This includes events where a patient is harmed, events where a patientis ​not harmed, events that are preventable, events that are not preventable and circumstances that could be unsafe. Pennsylvania legislators had the foresight almost 20 years ago when writing the Medical Care Availability and​Reduction of Error Act​ (MCARE) to require the reporting of all events. With 97% of the events reported causing no harm to patients, we would be left with very little to analyze and learn from if these had been excluded.
  4. Patients have a right to be fully informed of the care they receive. About 3% of the events reported meet the Pennsylvania definition of a serious event: an event that causes unanticipated injury and requires the delivery of additional healthcare services. Your facility is required to provide written notification to the patient and/or their family of a serious event when it ​occurs. Talk to your patient safety officer about how this is handled. As a former patient safety officer and risk manager, I found it critical for someone (myself, the physician, or the appropriate clinical leader) to have a conversation about the ​​letter with the patient.

    The purpose of the letter is to provide an opportunity for dialogue, not just to check a box.


    The Patient Safety Authority (PSA) offers training to Pennsylvania patient safety officers and others on how to have these ​important conversations. We are also offering the Agency for Healthcare Research and Quality's Communication and Optimal Resolution (CANDOR) program to Pennsylvania healthcare facilities. If you wish to learn more, please have your patient safety ​​officer reach out to your facility's patient safety liaison.

  5. ​​Patient safety reports submitted to PSA are confidential. PSA does not require or suggest that patient and/or provider names are ever included in the reports. Information submitted by your facility to PSA to meet the reporting requirements is protected ​​from the Commonwealth’s Right to Know Law. Work prepared by your patient safety committee to meet the requirements of ​​​MCARE is protected​ from discovery in medical malpractice suits—when prepared and defended appropriately.
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​Why does all of this matter? Because together we are changing the culture around patient safety. Due to our joint efforts, reporting of all events has increased year over year across the Commonwealth, while events that cause significant harm to our patients have decreased—which is exactly what we set out to do.


Together we are saving lives. 

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About this blog

Regina Hoffman serves as the  executive director of Pennsylvania’s Patient Safety Authority and editor-in-chief of Patient Safety, its award-winning journal.  Ms. Hoffman was recognized by Becker’s Hospital Review as one of the top 50 experts leading patient safety in both 2018 and 2020. This blog serves as a source for her to share her insights in patient safety and leadership with Pennsylvania’s healthcare leaders.

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***​ The views and opinions expressed at or through this blog are the opinions of the author alone and may not reflect the opinions or positions of the Patient Safety Authority or the Commonwealth of Pennsylvania, nor do these views represent in any way medical or legal advice. ​ 


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