For Pennsylvania Healthcare Employee Use Only
If you are a healthcare worker within Pennsylvania and believe a patient in your facility suffered an unanticipated injury involving clinical care, your first obligation is to report this internally via your organization's patient safety plan. If you are not satisfied with the manner in which the report was handled by the organization, you can submit an Anonymous Report to the Patient Safety Authority. Please note that submitting an Anonymous Report to the Patient Safety Authority does not also notify the Pennsylvania Department of Health.
All information submitted via this process is confidential and will be held in strictest confidence by the Patient Safety Authority.
To submit an Anonymous Report, click the icon link below. Complete the form to the best of your ability and return to the Pennsylvania Patient Safety Authority. There are three ways to provide the anonymous report to the Pennsylvania Patient Safety Authority.
- Electronically send
(recommended)
- Print a blank form to fill out manually and mail
- Print information to send via mail or print digitally as a PDF and send via email
To submit via mail:
Pennsylvania Patient Safety Authority
333 Market Street - Lobby Level
Harrisburg, PA 17101
If you are not a healthcare worker, do not use this form. You can submit a complaint to the Department of Health at:
https://apps.health.pa.gov/dohforms/FacilityComplaint.aspx.
