Patient Safety Authority
The Patient Safety Authority (PSA) is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires healthcare facilities to report all incidents of harm (serious events) or potential for harm (incidents).
The PSA analyzes those reports to prevent recurrence—either by identifying trends unapparent to a single facility or flagging a single event that has a high likelihood of recurrence—and disseminates that information through multiple channels.
Fast Facts
Founded in 2002 by the Pennsylvania Medical Care Availability and Reduction of Error Act (commonly referred to as "Act 13" or "the MCARE Act")
Vision: Safe healthcare for all patients
The Pennsylvania Patient Safety Reporting System (PA-PSRS) is one of the largest patient safety databases in the world, with more than four million event reports
The PSA is governed by an 11-member board appointed by the governor and Pennsylvania legislature
The Power of Reporting
A few years ago, a facility called with a concern regarding misplacements of nasogastric feeding tubes. Several clinical staff members (with decades of combined experience inserting tubes) were suddenly inserting them in patients’ lungs instead of their gastrointestinal tract, and they wanted to know if anyone else had reported the same issue. Two other facilities had.
A popular manufacturer stopped producing the enteral devices, forcing facilities to find an alternative quickly. This facility ordered a replacement of the same size and type but communication of the change did not reach front line staff who were placing the feeding tubes. The veteran staff continued to place the tubes as they always had—without realizing they were using a different product. Once the change was revealed to the staff, they commented that the new tubes did seem less pliable and slicker than the previous ones.
The broad overview provided by PA-PSRS allowed the PSA to accurately diagnose the root cause and alert others about the issue.
While reviewing high harm events, a PSA 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 would be nearly 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.
