Aggregate Data Summaries, the Strategic Plan through 2020, and Agency Highlights All Features in this Year’s Report
Harrisburg, Pa., May 1, 2017
— In its 2016 annual
report, the Pennsylvania Patient Safety Authority recognizes the patient safety
improvements made by Pennsylvania healthcare facilities, and discusses the
agency’s continuing efforts associated
with data collection and analysis, information dissemination, education and
outreach, collaborations, and partnerships. In addition, the Authority
highlights aspects of its 2017–2020 strategic plan, which includes extended
outreach to patients and other sectors.
In 2016, Authority board and staff
engaged in the Authority’s third strategic planning process, in which
participants developed a mission statement, vision, and four strategic pathways
of focus on (1) improving diagnosis, (2) the patient, (3) long-term care, and
(4) evaluating the reporting system. While the Authority remains committed to
its key programs, it also believes that expanding its outreach to patients and
other areas will enhance patient safety for all patients in the Commonwealth.
“As patient safety challenges change,
over time, our focus must also change,” said Rachel Levine, MD, chair of the
Authority board of directors. “As we carefully considered our
strategic plan through 2020, we recognized that the Authority has one of the
most robust reporting programs in the nation, and that aggregate data analysis,
when combined with the expertise of our board and staff members, helps us to
improve patient safety in the Commonwealth.”
Acute healthcare facility reporting
trends evident in 2016 include an overall increase in the number of events
reported (255,714, up 7% from 2015). The Authority continues to observe an
increasing percentage of events reported as Incidents (n = 248,166;
events that do not harm the patient), rather than Serious Events (n = 7,548; events that harm the
patient). The number of high-harm events (associated with
permanent harm or death) continues to trend downward; of high harm events in
2016, events that may have contributed to or resulted in the patient’s death is
the second fewest for a full year of reporting in the program history (218,
13.8% decrease from 2015).
“The Authority has hypothesized that a
decrease in reported high harm events could be associated with improvements
realized in patient safety, such as a shift to earlier detection and fewer
events reaching the patient and causing serious harm,” said Levine.
“In 2016, the Authority has also continued to observe improvements in
overall Serious Event reporting since new standards went into effect in April
2015.”
Nursing homes reported 27,544
healthcare-associated infection (HAI) events in 2016 (a 13% decrease from 2015),
and 2016 also marked the second full year of data collection since revised
reporting criteria was implemented in 2014. Some highlights of the event data
include that catheter-associated urinary tract infections were the predominant
urinary tract infection by rate and reported gastrointestinal infection events
decreased (statistically significant) compared to such reports in 2015. Also of
note, a discussed similarity in Pennsylvania and national flu trends reinforces
the need for continued efforts to protect nursing home residents from flu when
the incidence in the community is unusually large.
“The importance of infection control
and prevention in both acute healthcare facilities and nursing homes remains a
key component of the patient safety conversation. With state-wide initiatives
such as antibiotic stewardship at the forefront, standardized reporting criteria
to produce actionable data will be essential to current and future education
efforts,” said Levine.
Throughout the year, data queries from
event reports led to dissemination of analysis and guidance through the
Authority’s journal, the Pennsylvania Patient Safety
Advisory. As
of December 2016, the Advisory has provided nearly 540 safety-focused
articles and nearly 50 associated “toolkits” of assessment tools and
education. Authority staff, patient safety professionals, and
subject matter experts use a variety of Authority educational resources to
engage healthcare providers and provide patient safety strategies.
In 2016, educational programs engaged
nearly 10,600 participants collectively through regional/other presentations,
webinars, onsite at healthcare facilities, and through the Authority’s online
education system. The Authority also further enhanced its patient
safety liaison (PSL) outreach to reporting facilities with “Keystones” (i.e.,
targeted, topical outreach to facilities accompanied by consultative tools and
resources).
To date, Pennsylvania healthcare
facilities credit the Advisory with contributing to more than 4,650
structure and process improvements. Topics addressed during 2016 include
surgical procedures, medication-related events, infection prevention, maternity,
leadership, patient/family involvement, and teamwork.
While the Authority continues to
strengthen its foundational efforts and strategically prepare for the future, it
also proudly recognizes the value of collaborative learning. Success through
2016 in the Authority’s collaborative improvement projects on targeted
interventions in healthcare facilities has led to additional programs with
Authority partners.
Lastly, regarding healthcare staff engagement,
the Authority completed its fourth annual “I Am Patient Safety” contest in which
healthcare facilities again had the opportunity to display their commitment to
patient safety by nominating the outstanding patient safety efforts of their
staff. The Authority recognized 14 individuals or groups from
nominations from Pennsylvania facilities, all of whom are featured in the 2016
annual report.
See the Pennsylvania Patient Safety Authority’s
2016 Annual Report, which includes a virtual tour of the Executive Summary.
About the Pennsylvania Patient Safety
Authority:
Established under
the Medical Care Availability and Reduction of Error (MCARE) Act of 2002 the
Authority, an independent state agency, collects and analyzes patient safety
data reported through its Pennsylvania Patient Safety Reporting System (PA-PSRS)
and then provides strategies and lessons learned to healthcare facilities to
improve safety and help prevent patient harm.
Mission: To improve the quality of healthcare in
Pennsylvania by collecting and analyzing patient safety information, developing
solutions to patient safety issues, and sharing this information through
education and collaboration.
Vision: Safe healthcare for all patients.
For more information about the Authority, please
visit our website at www.patientsafetyauthority.org