Authority In The News | The Authority in the News

A new report on bullying by workers in Pennsylvania health-care settings found just 44 examples in two years, but it looked only at cases that were documented and could be linked to patient safety.

Proper use of Antibiotics can Prevent Resident Harm in Long-Term Care Facilities

Can You Help Prevent These Insulin-Delivery Errors?

Medical errors have harmed thousands in Pa. Tracking those errors is saving lives

New report looks at workplace bullying in Pa. health care

Bullying by medical professionals reduces quality of care, study finds

Study: Bullying Linked to Decline in Patient Safety

Attorney Veronica Richards Appointed to Pennsylvania Patient Safety Authority

Risks of New Technology Highlighted by Medication Errors in Pennsylvania Hospitals

In Pennsylvania, medication mistakes attributed to health IT

The Pennsylvania Patient Safety Authority Releases its 2016 Annual Report

PA Patient Safety Report: HIT Contributed to 889 Medication-Error Events in Six Months

The Pennsylvania Patient Safety Authority Refreshes Its Website

Patient Safety Errors are Common with Electronic Health Record Use

Williamsport attorney honored for patient safety

RSIs highlighted by former Joint Commission PSO in new advisory

UPMC Susquehanna hospital named patient safety contest winner

Allergies Most Common in Dietary Errors

Distractions Abound. Cross Monitoring Can Help.

2015

Bloomberg News: 'High Harm' Events in Pennsylvania Declined 45 Percent Over 10 Years

In its 2014 Annual Report released in May, the Pennsylvania Patient Safety Authority showed that adverse events in Pennsylvania healthcare facilities that led to death, near death or permanent harm to patients have dropped by 45 percent since mandatory reporting began 10 years ago. The article is reproduced with permission from the Bureau of National Affair's Health Care Policy Report, 23 HCPR 718 (May 11, 2015). Copyright 2015 by The Bureau of National Affairs, Inc. (800-372-1033) This Bloomberg Healthcare Policy Report was published on May 1, 2015.

2014

Mining Pennsylvania Error Data Suggests Patient Safety Gains From Advanced EHRs

According to a study published September 2014, data collected by the Pennsylvania Patient Safety Authority showed that electronic medical records' (EMRs) advanced functionality led to a 27% decline in patient safety events. The Authority found that this overall decline was driven by declines in several important subcategories: 30% decline in events due to medication errors and 25% decline in events due to complications. The iHealthBeat article was published November 2014.

Reconsidering the 12-Hour Shift for Nurses

Data from the Pennsylvania Patient Safety Authority highlights the risk of healthcare worker fatigue. The Authority found that 1,600 reports from June 2004 through August 2013 revealed that 88.5% of the incidents were reported resulting, at least in part, from healthcare worker fatigue. Thirty-seven of the incidents reported resulted in serious harm, including four that ended in the death of the patient. The Healthcare Traveler article was published July 2014.

Pennsylvania Patient Safety Authority Surgical Fire Data and Education Contributes to Modern Healthcare Magazine Article

Pennsylvania Patient Safety Authority data and education on surgical fires contributes to magazine article for raising awareness. The Modern Healthcare article was published July 2014.

Pennsylvania Patient Safety Authority Central Venous Catheter (CVC) Data Contributes to National Agency Article

Central venous catheters (CVC) removal while a patient is in an upright position, as described in this case, has been identified as the most frequently reported contributing factor for CVC-associated air embolism formation in an analysis of over 7 years of air embolism events submitted to the Pennsylvania Patient Safety Authority. The Agency for Healthcare Research and Quality article was published June 2014.

Pennsylvania Data Highlighting Healthcare Worker Fatigue Contributes to Article in Lehigh Valley Publication

The Pennsylvania Patient Safety Authority reports that health care worker fatigue was cited as a contributing factor in more than 1,600 events between June 2004 and August 2013 — 37 of them causing harm and four resulting in patient death. This Lehigh Valley Business article was published June 2014.

Pennsylvania Patient Safety Authority Contributes Data for Article About Emergency Department Workers and Violence Statistics

In 2010, the U.S. Bureau of Labor Statistics reported 11,370 assaults on healthcare and social assistance workers nationally, a 13 percent increase over the previous year. The following year, the Pennsylvania Patient Safety Authority reported 384 acts of violence or verbal abuse, most of them threats, from 2006 through 2010. This Pittsburgh Post-Gazette article was published June 2014.

Patient Safety Authority collaboration with ASFs is highlighted in Outpatient Surgery Magazine

Reaching out to patients with a second pre-op phone call may help facilities significantly reduce the incidence of day-of-surgery cancellations, suggests a study published online by the Pennsylvania Patient Safety Authority. This Outpatient Surgery article was published March 2014.

Kathleen Fowler, at UPMC St. Margaret, is one of 10 people recognized in the Pennsylvania Patient Safety Authority's "I Am Patient Safety" poster contest

The Pennsylvania Patient Safety Authority recognized Kathleen Fowler and nine other health care workers and facilities for their work by featuring them on "I Am Patient Safety" posters. Fowler was honored for her work to reduce patient falls and to help workers stay safe as they move patients.

Pennsylvania Patient Safety Authority "instrumental" in helping eliminate wrong-site surgeries

The Patient Safety Authority's aggregate data helps Pennsylvania healthcare facilities reduce adverse events and prevent medical errors. This Pittsburgh Tribune-Review article was published February 2014.

2013

Pennsylvania Patient Safety Authority uses collaboration to implement evidence-based safe practices

The Journal of Public Health Research wrote an article that was published November 2013. The Commonwealth of Pennsylvania has followed the Institute of Medicine's recommendations and found that an essential intermediate step between analyzing reports and implementing safe systems is collaborative learning among healthcare institutions. The experience in Pennsylvania should be useful to other public organizations wishing to improve patient safety.

Patient Safety Authority reporting system mentioned for tracking electronic health record events

The Scientific American's Board of Editors mentions Pennsylvania created a mandatory reporting system for all medical errors in June 2004. This system has uncovered thousands of e-record problems - from misreported laboratory tests to incorrect prescriptions. Almost 90 percent of these reports are close calls instead of adverse events, but still the data help to pinpoint what is causing the problem. The Scientific American's Board of Editors article was published November 2013.

Errors in default settings of electronic medical record systems raise risks for patients

The Pennsylvania Patient Safety Authority released its Patient Safety Advisory article on errors related to default settings in electronic health record systems. The Pittsburgh Tribune-Review wrote an article about the data that was published Sept. 6, 2013.

How much do you know about the Patient Safety Authority?

The Pennsylvania Medical Society explains that the Pennsylvania Patient Safety Authority is one of the important governmental entities and the reports issued can be helpful in improving systems and processes in health care facilities. The Pennsylvania Medical Society article was published July 19, 2013.

Authority's prepublication article about infection control best practices in ambulatory surgery centers makes news

The article outlines strategies for ambulatory surgical facilities to comprehensively explore their areas of greatest challenge with implementation of surveillance techniques, sterilization, disinfection, environmental control, safe injections, and standardized educational programs. The Infection Control Today article was published Jul. 17, 2013.

Handheld units help Kansas City doctors manage patients' data

A study by the Pennsylvania Patient Safety Authority found digital records error rates doubled from 2010 to 2011, perhaps reflecting growth in digital records use. The Kansas City Star News article was published Jul. 11, 2013.

Digital health records' risks emerge as deaths blamed on systems

According to a study published in December by the Pennsylvania Patient Safety Authority, the number of reports about medical errors associated with electronic records is growing. Of 3,099 incidents reported over an eight-year period, 1,142 were filed in 2011, more than double the number in 2010. The Bloomberg News article was published Jun. 25, 2013.

Why are medication orders going to the wrong patients?

A new study from the Pennsylvania Patient Safety Authority seeks to shed light on what is causing medication orders to get mixed up and go to the wrong patient. The Med City News article was published Jun. 7, 2013.

Hybrid EHR-paper workflows and medical errors

Healthcare organizations or providers using a mixture of paper and electronic records for clinical documentation are setting themselves up for potentially dangerous medical errors. Patient Safety Authority data is presented in this EHR Intelligence article published Jun. 3, 2013.

Pennsylvania Patient Safety Authority report: attendance up 70 percent

Attendance at Pennsylvania Patient Safety Authority's educational programs was up 70 percent in 2012, according to the authority's newly released annual report. The Central Penn Business Journal article was published May. 2, 2013.

Hospitals and medication errors

Patient Safety Authority medication event data and prevention strategies were cited in this article published in the Allentown Morning Call April 18, 3013. The article details medication events and strategies to prevent them.

Pennsylvania study reveals errors associated with EHRs

Pennsylvania's statewide reporting system of patient-safety incidents and serious events has yielded thousands of error reports that suggest electronic health records (EHRs) sometimes may cause drug mishaps rather than prevent them. The Pharmacy Practice News article was published April, 2013.

Is electronic health records "mania" hiding serious patient safety flaws?

The Pennsylvania Patient Safety Authority data is highlighted in this EHR Intelligence article published Feb. 20, 2013.

Study offers some clues on how to reduce $4.2 billion medication error dilemma

Medication errors are a huge problem for most hospitals and have been the focus of many studies; the issue was recently highlighted by the Pennsylvania Patient Safety Authority. The Med City News article was published Jan. 22, 2013.

Physician-patient alliance for health & safety: CMS proposed quality measure does not provide enough protection for patients using PCA

This article references the Pennsylvania Patient Safety Authority's Patient Safety Advisory article on safe PCA (Patient Controlled Analgesia) pump use. The Centers for Medicare and Medicaid Services (CMS) is considering a new proposed quality measure that calls for "appropriate monitoring of patients receiving PCA."

Health information technology patient safety action and surveillance plan for public comment

The Authority staff participated in a conference call with senior management from the Office of the National Coordinator for Health IT. Discussion centered around the Authority's December Advisory article on Pennsylvania's electronic health records adverse events and near misses in healthcare facilities.

The data, collected and analyzed by the Pennsylvania Patient Safety Authority, found that hospitals in the state reported twice as many EHR-related patient safety incidents in 2011 as in 2010. The American Medical News article was published Jan. 14, 2013.

Preventing errors associated with loading doses of medications

The Authority September Advisory article titled "Events Associated with the Prescribing, Dispensing and Administering of Medication Loading Doses" was cited in the Joint Commission Perspectives on Patient Safety newsletter, The Source, published Jan. 2013.

2012

Electronic health records may turn small errors into big errors

The Pennsylvania Patient Safety Authority data is also highlighted in this Med Page Today article published December 16, 2012.

Pennsylvania hospitals adopt safeguards against preventable surgical errors

This article published on the front page of the Philadelphia Inquirer highlighted Pennsylvania's efforts to reduce wrong-site surgery.

Patient Advocacy Group to Cut Hospital Mistakes Gets $1.6 Million

This article discusses recent funding the Authority received ($1.6 million) through a federal program called the Partnership for Patients. The Authority has partnered with the Hospital and Healthsystem Association of Pennsylvania (HAP) to take its wrong-site surgery, medication error and falls collaborations statewide. The article was published in the Philadelphia Med City News April 30, 2012.

Corbett Administration Wants to Fold Health Safety Agencies Into PA Department of Health

This article published in the Harrisburg Patriot News discusses the importance of the Authority's independence and possible consequences of a merger with the PA Department of Health to its patient safety educational programs. David Wenner wrote the article published Monday, April 2.

Infectious Cut: To do the job, health agencies need independence

This Pittsburgh Post Gazette editorial published March 19 supports the Patient Safety Authority maintaining its independence.

Safety Authority Opposes Corbett's Budget Plan

This article discusses the Authority's independence and what a proposed merger with the Department of Health could mean for the agency. Tim Darragh wrote the article published March 13, 2012.

Patient safety, cost agencies to move under Health Department

This article published in the Pittsburgh Post Gazette discusses the Authority's Independence and what a merger with the PA Department of Health could mean. Steve Twedt wrote the article published March 14, 2012.

Patient Safety Agency Says Losing Autonomy Jeopardizes Patients

This article and radio piece reiterates the importance of maintaining the Authority's independence in the best interest of improving patient safety. The piece aired March 12, 2012.

Patient Safety Panel Fighting Corbett Merger Plan

This article focuses on the Authority's efforts to maintain its independence through a resolution outlining the provisions in Act 13, 2002. The article was published in the Philadelphia Inquirer March 7, 2012.

Proposed Changes to the Patient Safety Authority's Independence Raise Important Policy Issues

Jeffrey C. Lerner, Ph.D., President and CEO, of ECRI Institute, wrote this opinion piece for the Pittsburgh Post Gazette on why it is important for the Authority to maintain its independence. The opinion piece was published March 6, 2012.

Corbett's Budget will set back Pennsylvania's Patient Safety Efforts

This blog, written by Michael C. Cohen, RPh, MS,ScD, President and CEO of the Institute for Safe Medication Practices and subcontractor for the Pennsylvania Patient Safety Authority, gives reasons why maintaining the Authority's independence from the PA Department of Health is crucial for its success. The blog was published February 28, 2012.

2011

Authority Data Shows Oral and Swallowing Care Are Key to Lower Infection Rates

The Pennsylvania Patient Safety Authority recently released an Advisory (December 2011) article giving nursing homes strategies on how they can reduce the risk of infection. This article, published in the long-term care business journal-- McKnight's Long Term Care News—discusses some of these risk reduction strategies provided by the Patient Safety Authority's senior infection prevention analyst.

Hospitals take steps to reduce errors among medical residents

The Pennsylvania Patient Safety Authority recognizes that hospitals have taken several steps to address risks associated with new medical residents. The Patriot-News article was published on Jul. 11, 2011.

Patients with Language Barriers May Be At Increased Risk of a Medical Error

The Pennsylvania Patient Safety Authority published a Patient Safety Advisory article that showed patients with a language barrier may be at increased risk of a medical error. The Authority gave guidance to facilities on how they can minimize the risk and the Pittsburgh Post Gazette highlighted the data in this article.

Anesthesiology and Wrong-Site Surgery

The Pennsylvania Patient Safety Authority clinical director Dr. John Clarke discusses the patient safety issues with anesthesiology and wrong-site surgery in the anesthesiology newsletter article.

As Norovirus Season Approaches, the Authority Gives Hospitals and Nursing Homes Risk Reduction Strategies

The Pennsylvania Patient Safety Authority released its December Patient Safety Advisory to help hospitals and nursing homes avoid or contain the norovirus. Tim Darragh of the Allentown Morning Call discusses the norovirus and the Authority's risk reduction strategies in this article.

Pennsylvania Patient Safety Authority Reporting System Considered Among the Best in the Nation

The Authority's clinical director and editor of the Pennsylvania Patient Safety Authority's Patient Safety Advisory, Dr. John Clarke, was interviewed recently by Hearst Newspapers for a story about medical errors and reporting systems. Of the 27 states that have reporting systems, the Authority ranks top among them for having the funding needed to analyze data and provide feedback to facilities which helps encourage reporting. The Authority has over 1.2 million events in its database, the second largest in the world with over 300 published academic articles based upon the data with strategies and guidance to help facilities improve patient safety.

Medical Malpractice Payouts Drop 61 Percent in Pennsylvania Since 2003

The payouts for medical malpractice have dropped 61 percent in Pennsylvania since 2003. In March 2002, the Pennsylvania Patient Safety Authority was created through legislation along with the MCare Fund. The fund is used to help doctors pay for medical malpractice costs. The Authority is mentioned in this Williamsport Sun Gazette article as a reform measure to help lower malpractice costs.

Pennsylvania Agency Reports 'Disruptive Behavior' in State Health Care

In its 2010 June Pennsylvania Patient Safety Advisory, the Authority released information pertaining to healthcare providers and how their disruptive behavior can jeopardize patient safety. Harrisburg Patriot-News reporter, David Wenner, interviewed several local healthcare providers to discuss how disruptive behavior in healthcare facilities can harm patients. The story was picked up by the Associated Press and several media outlets.

Surgical Fires and Reporting

This article published in the Cleveland Plain Dealer highlights surgical fires and reporting in Ohio. The Pennsylvania Patient Safety Authority is featured for its mandatory reporting program of Serious Events and Incidents for patient safety.

Hospital Infections Hard to Gauge

The Pennsylvania Patient Safety Authority's executive director is quoted in this article that details Pennsylvania's infection reporting program and discusses the complexities of reporting infections accurately.

Milestone for the Pennsylvania Patient Safety Authority

The Pennsylvania Patient Safety Authority recently reached a milestone in reporting. Over one million reports of serious events and incidents have been reported to the Authority. The Philadelphia Business Journal highlights the press release distributed that emphasizes the need for facilities to learn from the events and implement process changes. However, the number of events also reflects how far healthcare facilities have come in terms of reporting.

Hospitals in Southeastern PA Work to Improve Patient Safety

Hospitals in southeastern Pennsylvania are working together to prevent pressure ulcers (bed sores) in their facilities. This article from the Bucks County Courier Times shows what the hospitals are doing to improve patient safety in their facilities. The Pennsylvania Patient Safety Authority data is mentioned.

Lost Decade for Patient Safety

This editorial column by David Fallk examines the road taken by the healthcare industry since the 1999 IOM Report "To Err is Human" was released. In the report, it was shown that preventable medical errors were killing up to 98,000 Americans annually. Fallk points out that since 2002 medical malpractice lawsuits have declined 40 percent. The Pennsylvania Patient Safety Authority data is mentioned.

Pennsylvania Nursing Homes Begin Reporting Healthcare-Associated Infections

Pennsylvania nursing homes in the eastern part of the state began reporting healthcare-associated infections to the Pennsylvania Patient Safety Authority for educational purposes and to the Pennsylvania Department of Health for regulatory purposes. This piece from WHYY radio discusses the issue with the Authority's executive director and others.

St. Christopher's Hospital Eliminates Ventilator-Associated Pneumonia in the NICU

The Pennsylvania Patient Safety Authority published an article in its Patient Safety Advisory on the success of St. Christopher's Hospital in Philadelphia with preventing ventilator-associated pneumonia (VAP) in the neonatal unit (NICU) of its facility. This article from the Philadelphia Public Health Examiner discusses the issue of VAP and newborns.

Medical Mistakes are Unhappy Reality

Wrong-site surgery continues to be a serious problem in many healthcare facilities which is the focus of this article from The Atlanta Journal-Constitution. The Patient Safety Authority's Clinical Director, Dr. John Clarke, discusses the frequency of wrong-site surgeries in Pennsylvania and other states.

Hospitals in Wisconsin Battle with Color-Coded Wristband Standardization

The Authority is mentioned in this article out of Wisconsin that discusses the risks associated with color-coded wristbands. The Authority near miss that began the nationwide discussion for color-coded wristband standardization is highlighted.

Finding a Way to Ask Doctors Tough Questions

The Patient Safety Authority has educated the public about the importance of patients and their families participating in their healthcare. Pennsylvania's healthcare facilities also encourage their patients to ask questions. A recent study in Pennsylvania shows that consumers are participating more in their healthcare. This article in The Wall Street Journal discusses the issue with the Authority's clinical director.

Authority Data Shows Oral and Swallowing Care Are Key to Lower Infection Rates

In Just a Flash, Simple Surgery Can Turn Deadly

Although rare, surgical fires remain a concern for healthcare providers working in operating rooms. Studies show in the United States about 650 surgical fires occur each year. The Wall Street Journal published an article about the risks of surgical fires and discusses the importance of prevention with the Patient Safety Authority's clinical director.

Confusion Over Patient End-of-Life Wishes

The Patient Safety Authority published data in its 2008 December Patient Safety Advisory that showed healthcare providers and patients may not understand the differences between a living will and a do-not-resuscitate order. A news article in The Intelligencer explained why it is important for patients to ensure their end-of-life wishes are understood by their family members and healthcare providers.

Banding Together, Uniform Safety Alerts Hospital Coalition's First Priority

The Northeast Indiana Patient Safety Coalition credits the Authority for bringing the issue of the risks associated with color-coded wristbands to the national forefront.

Doctor Stands Up for Patient Care, Wins Case

The Authority is mentioned in this case out of California for its whistleblower protection established for physicians and other healthcare providers. The article is from American Medical News.

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