​"I think I can state that patient safety is probably the one area where we would all agree that we should be cooperating and not competing.”
—Pennsylvania Patient Safety Officer

All patient safety officers (PSO) struggle at times with demonstrating positive outcomes for changes undertaken at their facilities. Many PSOs have indicated that the Pennsylvania Patient Safety Authority has helped improve patient safety by raising awareness of significant issues and providing resources to address them. Contents herein are a collection of such resources that may be of use to PSOs. The Authority also encourages PSOs to contact their respective Patient Safety Liaison for more information.

Excerpted from: Pennsylvania Patient Safety Authority. A conversation with patient safety officers. 2007 Mar [cited 2017 Jun 7]. http://patientsafety.pa.gov/NewsAndInformation/Brochures/Documents/Brochure_Conversation_2007_2.pdf

​Event Reporting in Pennsylvania

Submission of Event Reports through the Pennsylvania Patient Safety Reporting System

The Pennsylvania Patient Safety Reporting System (PA-PSRS) is a secure, web-based system that permits medical facilities to submit reports of "Serious Events" and "Incidents" involving patients, as defined by the Medical Care Availability and Reduction of Error (MCARE) Act. Statewide mandatory reporting through PA-PSRS went into effect June 28, 2004. All information submitted through PA-PSRS is confidential, and no information about individual facilities is made public. The Department of Health can issue sanctions and penalties, including fines and forfeiture of license, to healthcare facilities that fail to comply.

As defined by the MCARE Act, PA-PSRS is a facility-based reporting system. Other complaint systems are available for individual citizens. Citizens can file complaints related to hospitals and ambulatory surgical facilities by calling the Department of Health at 1-800-254-5164. The website to file complaints is http://www.health.pa.gov/facilities/Consumers/Complaints/Pages/default.aspx. Complaints against licensed medical professionals can be filed with the Department of State's Bureau of Professional and Occupational Affairs at 1-800-822-2113.

Facilities submit event reports through a process identified in each facilities' own patient safety plans, as required by the MCARE Act. However, the MCARE Act provides for one exception to this facility-based reporting requirement: a healthcare worker who feels that his or her facility has not complied with the MCARE Act reporting requirements may submit an Anonymous Report directly to the Authority.

Facility users can access PA-PSRS by means of a computer with Internet access and minimal, self-directed online training. Patient safety liaisons assigned to each acute healthcare facility provide additional guidance, and an on-call Help Desk is available during business hours.

To report an event, facility users respond to 22 core questions (e.g., check boxes, free-text narratives); the system directs to follow-up questions, based on the answers to previous questions.

Facility users provide demographic information (such as a patient's age and gender), the location within a facility where the event took place, the type of event, and the level of patient harm, if any. Patient and healthcare provider names are not solicited. Additionally, the report collects considerable detail about "contributing factors," such as staffing, the workplace environment and management, the impact of health information technology (HIT), and clinical protocols. Users are also asked to identify the root causes of Serious Events and to suggest procedures that can be implemented to prevent a reoccurrence.

Analysis, Resources, and Feedback

The Authority team that analyzes reports includes professionals with degrees and experience in medicine, nursing, pharmacy, health administration, risk and quality management, product engineering, and statistical analysis. Additionally, through its contract staff, the Authority has access to a large pool of subject matter experts in virtually every medical specialty.

Based on this comprehensive analysis and augmented by review of healthcare literature and interviews with experts, the Authority develops and publishes articles and additional resources through the Pennsylvania Patient Safety Advisory. The Advisory articles are directed primarily to healthcare professionals, for use by both clinical and administrative staff to improve processes and outcomes. The articles are often supplemented by toolkits, many of which are interactive, that may be used to clarify and standardize reporting practices as well as to assess and improve patient care practices at the organizational, microsystem, or individual patient-care level. More information about the Advisory and the data collected through PA-PSRS is covered in The Pennsylvania Patient Safety Advisory section. Additionally, all issues of the Advisory are accessible on the Authority's website.

The Authority has also developed analytical tools within PA-PSRS that are available to reporting facilities. These tools provide patient safety professionals, quality improvement specialists, and risk managers with detailed reports analyzing data related to their specific facilities in a timely manner. Many reports can be exported to other software programs for inclusion in facility publications or reports and presentations to trustees and senior management. Additionally, facility personnel have the ability to export all, or any portion, of their own facility's data. Managers can use this information for their internal quality improvement and patient safety activities.

Excerpted from: Pennsylvania Patient Safety Authority. 2016 Annual Report. 2016 Apr 28 [cited 2017 Jun 7]. http://patientsafety.pa.gov/PatientSafetyAuthority/Pages/annual_report_2016.aspx