HARRISBURG: The Patient Safety Authority Board of Directors today approved a strategic plan that increases the educational outreach and collaborative efforts of the Authority for the next several years. Some initiatives include: Educating executive management and hospital boards on patient safety; reducing infections and increasing patient safety training and awareness to the provider community.
“The Authority’s first couple of years focused on building a reporting system that Pennsylvania healthcare facilities could easily use and encouraging facilities to report information into the system that could be put to good use,” said Dr. Ana Pujols-McKee, chair of the Patient Safety Authority Board of Directors. “Since mandatory reporting began in June 2004, over 100 Patient Safety Advisory articles have been written and hundreds of improvements have been made in healthcare facilities as a direct result of the guidance provided in the articles. But we know that much more work remains and a plan to put that work into action has been developed to take patient safety in Pennsylvania to the next level.”
The Patient Safety Authority is an independent agency that collects Serious Events (events that cause harm to the patient) and near misses (no harm) from Pennsylvania’s hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities. Over half a million reports have been submitted through the Pennsylvania Patient Safety Reporting System (PA-PSRS) since June 2004 with 96 percent of those events reported as near misses.
The plan calls for increased collaboration with Pennsylvania healthcare organizations, government entities and healthcare providers.
“Much of our plan involves working with other healthcare oriented individuals and groups to reach the common goal of increasing patient safety,” said McKee. “A top initiative is to work with HAP [Hospital and Healthsystem Association of Pennsylvania] to help hospital executives and boards understand the important role they play in improving patient safety in their facilities. Without the support of the CEO, many facility providers feel limited in the patient safety improvements they can make.”
McKee added that some of the patient safety initiatives coincide with elements of Governor Rendell’s ‘Prescription for Pennsylvania’ plan such as increasing patient safety education courses for providers, working to reduce hospital acquired infections and providing nursing home providers with guidance to prevent events from occurring in their facilities.
“The governor’s patient safety initiatives in his ‘Prescription Plan for Pennsylvania’ dovetail with many of the Authority’s action items,” said McKee. “The provision to increase patient safety educational initiatives parallels those the Authority will offer for its facilities and the provision to analyze nursing home data was an item we added to our plan because it made sense to give nursing homes the same opportunity to learn from their events and participate in educational training courses offered by the Authority.”
Under the provision, nursing home facilities would be required to pay a licensing fee per bed to pay for the analysis and production costs of the data. Another important patient safety provision in the plan, according to Michael C. Doering, interim executive director of the Authority, is the call for facilities to submit Patient Safety and Quality Improvement Reports.
“The governor’s plan calls for facilities to provide ‘Patient Safety and Quality Improvement Reports’ each year that will provide valuable information to facility providers and boards that they can use to direct future patient safety initiatives,” said Doering. “As facilities increase their vigilance in reporting events, the reports will also naturally increase, but so should our efforts to track the information and use it to change processes so that the event is prevented from happening again, whether it harmed a patient or not.”
Doering added that he expects most, if not all initiatives, will be implemented within the next three years.
For a detailed look at the Patient Safety Authority’s Strategic Plan, click here.
BACKGROUND
The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act, to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Under the Act, all Pennsylvania-licensed hospitals, birthing centers, ambulatory surgical facilities and certain abortion facilities are required to report what the Act defines as “serious events” and “incidents” to the Authority. More than 480 healthcare facilities are subject to Act 13 reporting requirements.
More than 500,000 reports have been submitted through PA-PSRS since the program was initiated in June 2004. Ninety-six percent of these reports are Incidents or “near-misses.” Based on those reports, the Authority issues quarterly and supplementary Patient Safety Advisories to advise hospitals and other healthcare facilities about steps they can take to reduce and prevent patient harm.
###
