Changemakers: Stories That Made a Difference
​​​​​​​​​​​​​​​​​​​Pennsylvania hospitals are required to report patient safety events, but do you know why it’s so important? Event reports can be the first indication of underlying problems, regardless of whether harm occurs. They also can be tools to trigger change facilitywide—or even nationwide.

Click one of the categories below or type keywords into the search field to find stories of event reports that inspired staff to make changes that improved patient care and safety throughout their hospital.

Featured Story
mother holding her newborn infant on her chest
​​​​While reviewing high harm events, a Patient Safety Authority analyst noted a report describing the near-death of a newborn after the mother fell asleep with the baby in her arms. The event prompted the analyst to determine whether any other similar events had occurred, and what she found was shocking: dozens of reports of newborns falling across the state, every year.

Because an individual facility may only experience one or two newborn falls annually, it was virtually impossible to measure the true scope of the problem without a broader perspective. The analysis—the largest one to date—brought light to an otherwise hidden and life-threatening issue. To further raise awareness of infant falls on a national level, the PSA collaborated with a facility to produce a safety video about the risks and how to protect against them.​

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