About PA-PSRS
The Pennsylvania Patient Safety Reporting System (PA-PSRS) is a secure, web-based system that permits healthcare facilities to submit reports of “serious events” and “incidents” as defined by Act 13 of 2002, Act 30 of 2006, and Act 52 of 2007. Statewide mandatory reporting to the Patient Safety Authority (PSA) through PA-PSRS went into effect on June 28, 2004, for hospitals, ambulatory surgical facilities, and birthing centers. In 2006, legislation was signed into law requiring that abortion facilities that perform more than 100 procedures annually also must report serious events and incidents through PA-PSRS. In 2007, hospitals and nursing homes were charged with reporting healthcare-associated infections (HAIs) as serious events. Hospitals report HAIs to PSA, the Pennsylvania Department of Health (DOH), and the Pennsylvania Healthcare Cost Containment Council (PHC4) through the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). Nursing homes began reporting HAIs to PSA and DOH in June 2009.
PSA analyzes the data collected in PA-PSRS to identify trends and recommend changes in healthcare practices and procedures that may be instituted to reduce the number and severity of future serious events and incidents. PA-PSRS currently contains more than 5 million event reports, making it the largest database of its kind in the United States.
Reporting Decision Tree
Reporting Decision Tree
Determining whether or how an event should be reported can be difficult. The Reporting Decision Tree combines the elements of the statutory definitions from MCARE and the Final Guidance documents into a single, step-by-step algorithm to walk users through the nuances of reporting events in Pennsylvania.
Event Reporting Examples
The following serve as examples of how to report events into PA-PSRS.
Narrative: A patient received an order for 28 units of insulin via vial administration. The RN was unfamiliar with this type of dosing for insulin and thought the entire vial was to be given via a 10 mL syringe. When scanning the vial, the correct units came up (no partial dose indication), and they proceeded to administer the entire vial. The patient developed hypoglycemia and required transfer to the intensive care unit (ICU).
Narrative: Patient presented to the emergency department four days post C-section with chest pain, headaches, and shortness of breath. Lab work showed an elevated D-Dimer and CT angiogram was consistent with a pulmonary embolism. The Emergency Department (ED) physician prescribed Eliquis, and the patient was discharged after the first dose was given in the ED.
Narrative: Patient safety in Pennsylvania is largely directed by Pennsylvania’s Medical Care Availability and Reduction of Error (MCARE) Act, which requires some healthcare organizations to report incidents, serious events, and infrastructure failures (see MCARE for definitions) into the Pennsylvania Patient Safety Reporting System (PA-PSRS).1 Many variables, including the complexity of healthcare, impact reporting and create inconsistencies.
Narrative: Patient presented to reproductive ASF for egg retrieval in 10/10 pain. Discussed differential diagnosis and treatment options. Decided to proceed with egg retrieval to see if that would relieve pain. It did not. Patient was sent to hospital to have procedure done to rule out ovarian torsion.
Narrative: Patient with a recent CVA was ordered a pureed diet with thickened liquids. Three days later, the diet order was revised to a pureed diet with thin liquids, but the recommendation for thickened liquids remained in the order comments. Due to the inconsistency between the order and the comments, dietary staff held the meal tray until the order could be clarified. The patient did not receive a meal tray for 4 days. Patient developed acute kidney injury, likely from poor oral intake. Kidney injury resolved after oral intake was resumed.
Narrative: Mother presented to her physician office for a labor check with high-risk pregnancy and complaints of diaphoresis, dizziness, and vomiting. Fetal heart tones were unable to be obtained and the patient was sent to the hospital. During initial assessment at the hospital fetal heart tones were still unable to be obtained. Ultrasound confirmed fetal demise. Sudden gush of blood noted, and diagnosis of placental abruption made. Baby was delivered stillborn via Cesarean section.
Narrative: A patient returns to the operating room for a uterine repair 2 days post c-section.
Narrative: Intravitreal medication was injected into the incorrect eye. Intravitreal medication was then injected into the correct eye.
Narrative: The final sponge count indicated a missing sponge. The patient was still in the operating room, but the incision was already closed. The surgeon reopened the incision and retrieved the sponge.
Narrative: A drill bit broke during orthopedic surgery, and the tip became lodged in the patient’s femur. The surgeon made the decision to leave the drill tip in place because risks associated with removal outweighed the benefits of removal.
Narrative: Following cardiac surgery, surgeon packed patient’s chest with four lap sponges and intentionally left them in place with chest open. During patient’s planned return to the OR, the sponges will be removed prior to closing the chest.
Narrative: Patient dislodged nasogastric tube several times, resulting in multiple reinsertions. Chest X-ray after last reinsertion revealed bilateral pneumothoraces. Bilateral chest tubes placed.
Narrative: The patient status post nasogastric tube insertion. Chest X-ray revealed a misplacement into the left lung with a small pneumothorax. Patient did not require a chest tube. Patient will continue to be monitored for respiratory distress.
Legislation & Guidance
The Medical Care Availability and Reduction of Error (MCARE) Act of 2002 (also referred to as "Act 13") requires acute care facilities in Pennsylvania to report instances of harm (i.e., serious events) and near misses (i.e., incidents) to the Patient Safety Authority (PSA).
Act 52 of 2007 requires certain healthcare facilities in Pennsylvania to report healthcare-associated infections to the Pennsylvania Department of Health, the Pennsylvania Health Care Cost Containment Council (PHC4) and PSA through the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Medical Care Availability and Reduction of Error (MCARE) act – Extending Patient Safety Standards to Certain Abortion Facilities
Act 88
Medical Care Availability and Reduction of Error (MCARE) Act – Omnibus Amendments
This announcement serves as final notice to healthcare facilities about reporting requirements to the Authority under the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Health Care-Associated Infections.
Final guidance for acute healthcare facility determinations of reporting requirements under the Medical Care Availability and Reduction of Error (MCARE) Act.
This announcement serves as final notice about updates to healthcare-associated infection reporting criteria for Pennsylvania nursing homes for mandatory reporting to PSA and the Department of Health under Act 52 of 2007.
Final guidance for acute healthcare facility determinations of reporting requirements for pressure injuries under the Medical Care Availability and Reduction of Error (MCARE) Act.
Bylaws of the Patient Safety Authority (as amended June 1, 2010)
This outlines the Right-to-Know Policy for the Patient Safety Authority (last revised on October 2, 2024).
PA-PSRS Data Interface
The Patient Safety Authority (PSA) supports the PA-PSRS Automated Data Interface (Data Interface) to accept Incident reports from MCARE Act of 2002 (Act 13) reporting facilities directly through their existing internal incident reporting systems. The Data Interface cannot be used by Nursing Home facilities that report healthcare-associated infections under Act 52 of 2007. The Data Interface also cannot be implemented or used for Serious Event reports. Only facilities reporting Incidents can develop a Data Interface with PSA. Facilities that want to develop Data Interface capabilities should contact the (Pennsylvania Patient Safety Reporting System) PA-PSRS Support desk at support_papsrs@pa.gov.
Links to the PA-PSRS Automated Data Interface Specifications are accessible below. Please note that all information provided regarding the PA-PSRS Data Interface specifications including but not limited to information regarding the data structure and processing logic of PA-PSRS is owned exclusively by PSA. This information may be used only in connection with, and solely for the purpose of, the development of the Data Interface between PA-PSRS and an internal reporting system at a medical facility that is both (1) physically located in the Commonwealth of Pennsylvania and (2) subject to the reporting requirements of Act 13. All other use is prohibited without the express written permission of PSA.
Notice to Facility Users
The Automated Data Interface Specifications now reflect the changes made to the Data Interface schema that took effect on January 1, 2022. See schema version 8.1. After December 31, 2021, all facilities may only submit files to the PA-PSRS Data Interface using schema version 8.1. Original correspondence regarding these changes can be found here.
PA-PSRS Automated Data Interface XML Specifications for schema version 8.1
Requirements for participating in the data interface:
Part 1: System Description
Part 2: XML Document Definition
Part 3: Appendix
