What Does the Data Tell Us?
Each year, thousands of people await the release of the Patient Safety Authority’s (PSA) annual data, but what does the data really mean? In 2020, Pennsylvania hospitals, ambulatory surgery facilities, abortion facilities, and birthing centers entered almost 280,000 patient safety reports into the Pennsylvania Patient Safety Reporting System (PA-PSRS). This includes serious events: events that cause injury to a patient and require additional healthcare services, and incidents: events that either result in minor injury or do not reach the patient at all.
An example of a serious event: A patient receives a new medication and experiences a severe allergic reaction to it. The nurse needs to insert an intravenous catheter into the patient’s arm and administer medication to stop the reaction. No error occurred—the patient nor the healthcare team knew the medication would cause an allergic reaction.
A serious event may be preventable, but it also may not be.
An example of an incident: The patient’s physician orders digoxin (a heart medication) to be given in a dose of 0.125 mg. The nurse pulls the correct medication but in a dose of 0.25 mg. The nurse notices the dosage discrepancy before they give it to the patient. This is an incident because the error was caught before it reached the patient.
Incidents are important to discuss because they provide an early warning signal to a potentially broken process. In this case, the healthcare facility will want to understand how and why the nurse accidentally pulled the incorrect dose. Was it in the wrong drawer? If so, how did it end up there? Maybe the carton was labeled incorrectly which led to the stocking error. If we don’t take the opportunity to learn from incidents, we lose the opportunity to prevent real harm.
In 2020, 97% of the reports submitted to PA-PSRS were incidents.
It would be better to see the number of reported events decrease each year, because fewer reports means safer care, right? Well, not exactly. PSA has worked closely with Pennsylvania healthcare facilities year after year because we want to see these numbers—especially reported incidents—increase.
Why would we want these numbers to increase?
To understand why, you first need to understand where we started. Two decades ago, physicians, nurses, and other healthcare professionals seldom reported such events. It doesn’t mean they didn’t occur, but few people discussed them. By not acknowledging or studying them, we couldn’t learn from them to improve care.
Since then, healthcare facilities and organizations like PSA have worked to create a culture where healthcare workers aren’t afraid to speak up when a patient safety event happens. In an environment where transparency is a core value, patient safety event reporting increases.
Since mandatory reporting commenced in Pennsylvania in 2004, we have seen the number of reports increase over time—which is exactly what we wanted.
PSA uses the PA-PSRS data to identify patient safety issues that require immediate focus and those that are continually shared through statewide education, collaboration, and publication.
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.