Annual Report

April 2018

2017 Patient Safety Authority Annual Report

All Annual Reports

Masthead

Board of Directors

Rachel Levine, MD (Chair), Physician Appointed by the Governor

Stanton Smullens, MD, (Vice Chair)

Radheshyam Agrawal, MD

Jan Boswinkel, MD

John Bulger, DO, MBA

Daniel Glunk, MD

Arleen Kessler, PharmD, MBA, RPh,

Mary Ellen Mannix, MRPE,

Veronica Richards, Esq.,

Linda Waddell, MSN, RN,

Leadership

Regina M. Hoffman, MBA, RN, Executive Director
Howard Newstadt, JD, MBA, Sr. Director, Finance & Business Ops/CIO/CISO
Rodney R. Akers, Esq., Legal Counsel
Michelle Bell, BSN, RN, Director, Outreach & Education
Rebecca Jones, MBA, RN, Director, Data Science & Research

Staff
JoAnn Adkins, BSN, RN, Senior Infection Preventionist
Jeffrey Bomboy, BS, RN, Senior Patient Safety Liaison
Kelly R. Gipson, BSN, RN, Project Manager
Richard Kundravi, BS, Patient Safety Liaison
Christopher Mamrol, BSN, RN, Patient Safety Liaison
Karen McKinnon-Lipsett, Admin. Specialist, Executive
Shelly M. Mixell, Executive Assistant
Melanie A. Motts, MEd, RN,CPPS, Patient Safety Liaison
Teresa Plesce, Office Manager/HR Liaison
Catherine M. Reynolds, DL, MJ, RN, Patient Safety Liaison
Terri Lee Roberts, BSN, RN, Senior Infection Preventionist
Megan Shetterly, MS, RN, Senior Patient Safety Liaison
Caitlyn Sidrane, MPH, Project Manager
Alex Ulsh, BCS,ITIL, Certified Systems Administrator/Deputy CISO
Susan Wallace, MPH, Patient Safety Liaison
Robert Yonash, RN, Senior Patient Safety Liaison

Contractors

Theresa V. Arnold, DPM, Manager, Clinical Analysis
Julia Barndt, MA, Associate Editor (Advisory)
Sharon Bradley, RN, CIC, Sr. Infection Prevention Analyst
Phyllis Bray, Database Administrator
John R. Clarke, MD, Clinical Director Emeritus
James Davis, MSN, RN, CIC, FAPIC, Sr. Infection Prevention Analyst
Eloise DeHaan, ELS, Copy Editor (Advisory)
Ellen Deutsch, MD, MS, CPPS, Medical Director, Editor (Advisory)
Cynthia Field, BSN, RN, NE-BC, CPHQ Patient Safety Analyst
Edward Finley, Data Analyst
Michael J. Gaunt, PharmD, Sr. Medication Safety Analyst
Matt Grissinger, RPH, FISMP, FASCP Manager, Medication Safety Analysis
Shawn Kincaid, System Developer
Ben Kramer, System Administrator
Susan Lafferty, Administrative Assistant
Kim Liberatore, MSN, RN, CPHQ, Patient Safety Analyst
Donna Lockette, Business Analyst
Mary Magee, MSN, RN, CPHQ, CPPS, Sr. Patient Safety/Quality Analyst
Willia Marella, MBA, MMI, Program Director
Christina Michalek, BSc, Pharm, PRh, Sr. Medication Safety Analyst
Jesse Munn, MBA, Operations Mgr., Managing Editor
Badal Sanghvi, MBA, It Manager
Carly Sterner, System Developer
Dawn Thomas, Communication Specialist

Executive Summary

2017 was a banner year for the Patient Safety Authority, no matter the barometer. Thirteen thousand professionals received training across hundreds of statewide and regional events; more than 4,000 people worldwide read the Advisory; and Authority staff were invited to speak at several national forums. Additionally, the Authority began a modernization project for PA-PSRS, the most robust reporting system in the nation for patient safety events and long-term care infections. The Authority also unveiled a standardized approach for reporting pressure injuries to provide a similar depth of analysis. Highlighted throughout this report are the steps the Authority took to further its vision of safe healthcare for all patients.

2017 Highlights

Executive Director, Regina Hoffman, presented to leaders at the American College of Medical Quality about Pennsylvania's achievements in patient safety.
Director of Innovation and Strategic Partnerships, Rebecca Jones, presented during a plenary session and pre-conference workshop at the Diagnostic Error in Medicine (DEM) conference in Boston, Massachusetts.
Liaison Susan Wallace was invited to speak about the use of patient sitters at the 2017 Safe Patient Handling and Mobility/Falls Conference in Glendale, Arizona.
Each of the Authority’s Infection Preventionists spoke at the annual conference for the Association for Professionals in Infection Control and epidemiology (APIC) in Portland, Oregon.
Infection Preventionist JoAnn Adkins was accepted as an APIC fellow. She joined Terri Lee Roberts and Jim Davis who received the honor in 2016.

Pharmacist Matthew Grissinger presented on prescribing errors at the National Patient Safety Foundation's (NPSF) annual Patient Safety Congress in Orlando, Florida.
In September, liaisons Kelly Gipson and Susan Wallace were asked to present to the Pennsylvania chapter of the Service Employees International Union (SEIU) about the effects of bullying.
The Authority, in collaboration with key stakeholders, developed a standardized process for reporting pressure injuries to better capture information about this serious safety concern.
A webinar on suicide prevention facilitated by liaisons Chris Mamrol and Rick Kundravi was attended by more than 250 people.
Infection Preventionist Sharon Bradley spoke to 400 leaders in long-term care at the Pennsylvania Directors of Nursing Administration’s (PADONA) annual conference in Hershey.
At the Respiratory Conference at the Slopes in March, liaison Bob Yonash presented on health literacy and proactive event reporting with a combined attendance of more than 400 people.
Liaisons Cathy Reynolds, Melanie Motts, Jeff Bomboy, and Megan Shetterly and system developer Shawn Kincaid held a four-part webinar series on health literacy with 600 people in attendance.
The Authority underwent a rebranding effort with a newly designed logo and website to better reflect its innovative spirit and distinct role in helping facilities protect patients.
Paul Epner, CEO and Co-Founder of SIDM, and Dana Siegal, Director of Patient Safety for CRICO Strategies, presented during a meeting of experts and stakeholders for the HAP HIIN Diagnostic Errors project led by the Authority and HCIF to develop measures for improving diagnosis.
The Authority continued its partnershipwith the Pennsylvania Society of Anesthesiologists to protect patients against wrong-site nerve blocks.
Medical Director, Ellen Deutsch, presented at HAP's 2017 Patient Safety & Quality Symposium breakout session, Safety: Are Humans the Problem or Can You Help Them Be the Solution?

Strategic Plan 2017 - 2020

VISION

Safe healthcare for all patients

FOCUS ON IMPROVING DIAGNOSIS

Analyze internal and external data to identify trends
Update PA-PSRS to improve data capture
Lead on ED radiology collaborative
Expand educational offering
Include focus on ambulatory clinics and practices

FOCUS ON THE PATIENT

Expand inclusion of patient perspective
Identify key topics
Educate patients on safe healthcare
Improve awareness of and access to resources

FOCUS ON LONG-TERM CARE

Identify key topics
Expand educational offerings
Lead an infection prevention collaborative

FOCUS ON EVALUATING THE REPORTING SYSTEM

Evaluate scope of patient safety events captured via PA-PSRS
Identify opporturnities to improve data capture

Mission

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

Overview

Thirteen million people live in Pennsylvania, yet 47 million visit one of its hospitals each year. Patients from across the globe seek our facilities with the hopes of reversing a lifetime of blindness, regaining their ability to walk, or receiving the first cancer treatment that may offer a cure. Our facilities sustain this excellence by constantly redefining medicine and providing patients the most revolutionary treatments for afflictions previously considered irremediable. Equally as important is ensuring that this care is delivered free from harm and safety is not sacrificed at the hands of innovation.

Enter the Patient Safety Authority. With the nation’s most comprehensive state reporting structure, the Authority has access to millions of data points specific to Pennsylvania. This provides insight into emerging trends that may not be apparent at the facility level.

During a specialized eye surgery, a patient was injured when a piece of equipment became dislodged mid-procedure. The apparent cause was user error, but after reviewing reports from across the state, it emerged this instrument had a significant manufacturing defect that has since been corrected. The Authority used this broad overview to identify four key pillars for healthcare facilities: 1) improving diagnosis, 2) focusing on the patient, 3) emphasizing long-term care, and 4) improving event reporting. Each was selected for its relevance and potential impact and have been incorporated into all Authority offerings.

Improving Diagnosis

Reviewed current patient engagement programs to identify best practices
Developed a Patient Voice Resource Pool to provide patients a forum to influence care
Utilized current information-sharing platforms, e.g., Facebook and Twitter
Developed consumer-focused education that explains key patient safety concepts

Patient Focus

Joined the Coalition to Improve Diagnosis to engage partners from other organizations committed to improving diagnosis
Partnered with the Health Care Improvement Foundation (HCIF), HAP, and CMS in a multi-year collaborative to decrease the risk of diagnostic error
Presented at the 2017 Diagnostic Error in Medicine (DEM) conference in Boston, Massachusetts
Developed a methodology for identifying and categorizing diagnostic errors among the events reported to the PA-PSRS database

Long-term Care (LTC)

Convened five regional focus groups to solicit input from LTC facilities and developed an antibiotic stewardship collaborative in response to their request for an increased focus on infections
Partnered with LTC associations and professional organizations to identify key areas of opportunity
Provided a broad range of education (including falls and pressure injuries) to LTC facilities during regional and statewide events

Event Reporting

Conducted a systemic review of PA-PSRS to improve its relevance, function, and contribution to patient safety improvement
Explored several opportunities to review other data sources to identify future enhancements within the PA-PSRS system, including court dockets, malpractice claims, and data from the Pennsylvania Insurance Department
Continued a multi-year project to enhance the reporting system through the Authority’s PA-PSRS modernization project

Educational Outreach

EducationAL Outreach by the Numbers

Improving Safety and Reducing Harm across the Care Continuum

The purpose of education is to create change. Without change, improvement can't occur. Education allows sharing of information about why to change, practical strategies to create change, and theory about how to achieve effective and lasting change. Education must also be accessible, both in content and in availability.

This is the foundation for the Authority's Educational Outreach- develop programs that address relevant topics, are interesting, and that recognize the realities and constraints on healthcare workers. To do so:

Topics are selected at the request of facilities, via analysis of event reports, or by identifying gaps in available resources.
Education is provided for a variety of knowledge levels from beginner to expert patient safety professionals, as well as programs designed for frontline staff and patients.
Presentations defy the notion that serious topics cannot be engaging by incorporating real-world examples and pop culture parallels.
Busy professionals can access resources, webinars, and toolkits on their smart phones when and where it is most convenient for them, and Authority staff frequently present on-site at facilities and organizations.

With this approach, participation in Authority events increased 23% from last year, educating more than 12,920 people across Pennsylvania. As the Authority continues to adapt its offerings, it expects to expand its reach and further protect more patients from harm.

Education Spotlight: Drexel University Law Students

While the bulk of patient safety focuses on frontline providers and administrators, there's an often-over-looked segment that is equally as vested in protecting patients: healthcare attorneys. While the clinical staff is addressing any physical harm, communicating with families, and complying with reporting requirements, the legal team is responding to complex questions requiring a degree of analysis and interpretation.

"What does informed consent really mean? What can we do to mitigate risk and potential liability in the future?" "Would this patient have been treated differently if they were another race or gender?" "Should they have been?"

As a healthcare compliance consultant and former federal prosecutor who focused on healthcare prosecutions, David Hoffman recognizes how difficult these questions can be and how important it is for his colleagues to understand the nuances of patient safety. When he became a Practice Professor of Law at the Kline School of Law at Drexel University, he took the opporturnity to provide his students a foundational framework and invited the Authority to assist. Cathy Reynolds, the liaison covering Philadelphia and Delaware County, spoke to his class about the history of patient safety and what role they could play in shaping its future. She also discussed the Authority's function and the resources it provides.

"Patient safety is more than just a regulatory requirement. It's a value that should be at the core of all of healthcare. The Patient Safety Authority are experts in this area. So when I decided to build this component into the curriculum, I knew they had to be involved." David Hoffman, JD, FCPP

Patient Safety Liaisons

The liaison program was started nine years ago to provide facilities guidance for navigating the MCARE Act and develop strategies to reduce harm. The original team of six now consists of eight professionals who bring a breadth and depth of knowledge and expertise.

This expertise translates into a broad range of services, from reviewing policies to identifying potential lapses in care to facilitating statewide collaboratives where frontline staff can discuss common issues and implement evidence-based best practices. Keystones are focused campaigns that reflect challenges reported throughout the state. Liaisons work closely with facilities to identify how a given topic is affecting them, develop potential solutions, and educate staff.

The current Keystone, Keys to Engaging Leaders, kicked off on July 1st and will run for 12 months. This campaign was designed to demonstrate to senior leadership that "patient safety" is more than just a regulatory requirement. It's an opportunity to proactively prevent harm and improve care. More than 300 facilities met with their liaison in the first six months to identify opportunities to engage leaders within their organization.

In the Spotlight Wrong-site Surgery Consultation

Wrong-site surgery (WSS) is defined as a surgical procedure that involves operating on the wrong patient, wrong side of the body or body part, or when the wrong procedure is performed. As difficult as it can be to believe such an event could happen, approximately one WSS is reported in Pennsylvania every week.

Because an occurrence can be so devastating, preventing WSS has become a focus for the Authority.

Excela Health, a large health system in Western Pennsylvania, had reached a plateau. While their rates for WSS were relatively low, they were still unable to sustain their goal of zero. Excela partnered with the Authority to conduct an in-depth analysis to answer the fundamental question, “What are we missing?”

Bob Yonash, Senior Patient Safety Liaison for the South-west region of Pennsylvania, worked with Excela leadership to develop a multi-pronged approach: creating an awareness campaign, conducting OR observations with real-time feedback, and disseminating of WSS prevention strategies to surgical and anesthesia staff.

A few key areas of improvement were identified including revising the process for time-outs and site-marking, conducting teamwork training, and redefining strategies for pre-procedure verification.

As a result of these efforts, Excela has sustained rates of WSS to near zero, and the team has seen a noticeable improvement in safety culture across roles and disciplines.

I AM Patient Safety

Celebrating Pennsylvania’s Commitment to Patient Safety

Thank you to everyone who participated in our annual I AM Patient Safety contest!

Healthcare can be challenging. Long hours requiring constant excellence as patients entrust us with their lives. It can be so easy to get caught up in the daily grind, constantly focusing on any shortfalls, that we never stop to take a breath and celebrate all our successes. Every life saved. Every error prevented. Every extra mile given. But those are the moments that remind us why we chose this path and keep propelling us forward.

Here at the Authority we understand how vital this is and are proud to recognize the individuals and teams who have gone above and beyond to protect their patients and revolutionize the care they provide them.This year marked the highest ever number of nominations, with more than 200 submissions from 78 organizations.

A panel of judges reviewed entries spanning all corners of the Commonwealth, representing large academic medical centers, long-term care facilities, and ambulatory surgery facilities.

For the first time, participants selected from one of nine categories:

Good Catch
Individual Impact
Video
Long-Term Care
Improving Diagnosis
Innovation
Focus on the Patient
Ambulatory Surgery
Best Use of Authority Resources

The breadth and depth of the submissions- from a rapid response team who transformed their process for responding to a code to a registrar who prevented a wrong-site surgery through diligence and courage, reinforces why Pennsylvania continues to serve as the national leader in patient safety.

I’m proud to recognize this year’s winners and encourage everyone to continue to celebrate the positive.

Regina Hoffman, MBA, RN

Executive Director, Patient Safety Authority

2018 Winners

Improving Diagnosis

Einstein Medical Center Montgomery

Janet Cahill

Good Catch

Lehigh Valley Hospital Muhlenberg

Dawn Emes

Focus on the Patient

Cancer Treatment Centers of America,
Eastern Regional Medical Center

Hannah Do

Innovation

UPMC Presbyterian Shadyside

Sarah Cua, Lisa Donahue, Kristian Feterik,Carol Mathews, Cecilia Zamarripa

Long-term Care

Crosslands

Heather Kline

Ambulatory Surgery

Shriner’s Hospital for Children Erie

Deborah Balogh

Individual Impact

Einstein Medical Center Montgomery

Raymond J. Cipollini

Video

UPMC Susquehanna - Williamsport

Laura Fry, Melissa Furman, Becky Hess,Ellen Kramer

Best Use of Authority Resources

Chester County Hospital

Katie Costantini, Ann-Louise Jeffery, Jodi Levine, Janeen Smith, Trish Ward, Liz Waterhouse

Improving DIagnosis

Executive Director’s Choice

UPMC Hamot

Michelle Nelsen

Improving Diagnosis

Einstein Medical Center Montgomery

Janet Cahill, M, MT, ASCP

Janet Cahill championed and presented a strong business case to implement accurate testing technology for identifying pathogens, improving diagnosis outcomes, and enhancing antibiotic stewardship for the entire facility.

Microbiologist Janet Cahill, in collaboration with the antibiotic stewardship team, championed a diagnostic change that improved patient care. Her project implemented a new use of polymerase chain reaction (PCR) testing for influenza (the flu). Cahill worked with the information technology (IT) team to ensure the PCR tests would interface properly and the information would flow to the prescribers and pharmacy.

Although the earlier type of test had a sensitivity of 85% in detecting influenza type A and 59% for influenza type B, the new PCR test was much better, being 100% sensitive for both flu types. This allowed the hospital to avoid giving oseltamivir, a drug commonly used to treat the flu, to flu-negative patients, who would not benefit. The proportion of patients who did not have the flu but did receive oseltamivir improved, falling from 19.1% during the flu season before the project to 1.9% the flu season after.

The mean length of hospital stay for patients who received at least one dose of the drug fell from 6.39 days to 3.95 days. Although the PCR test is costlier than the older test, its use prevented a significant amount of unneeded drug from reaching patients and shortened lengths of stay.

Cahill also championed use of another PCR test that identifies patients’ blood pathogens in 1 hour, down from 27–37 hours. Cahill’s efforts helped in pursuing the goal of reducing the use of inappropriate or unnecessary antibiotics.

Good Catch

Lehigh Valley Hospital Muhlenberg

Dawn Emes, RN

Dawn Emes not only recognized that telemetry alarms were not being sent to her pager, but identified an absence of telemetry alarms for the entire hospital, which led to the system being rebooted and potentially preventing missed nursing notifications of cardiac alarms. Late on a Sunday night, registered nurse (RN) Dawn Emes noticed that her telemetry pager, which tracks changes in patients’ heart rhythms, was not sending alarms for a patient she knew had arrhythmias.

The pager had been functioning properly at change of shift, three hours earlier. She found she was unable to send her pager a test page. Concerned, Emes tested all the RNs’ pagers on the unit and found they also were not working.

First, she stationed an RN at the telemetry monitoring station to watch all patients being monitored, recognizing the possibility of an event going unnoticed. Then she notified the nursing supervisor and asked if other units in the hospital were having this issue. Initially, she was told no; however, the nursing supervisor soon reported that the unit’s pagers were not sending alarms to the nurses on other units, which had gone unnoticed. The clinical engineering department rebooted the system and alarms functioned again.

Of all of the unit nurses with patients on telemetry,Emes was the only one to notice that it was a problem that alarms were absent and that the problem could be occurring across the hospital. While it cannot be said Emes prevented injury or death, she prevented all the patients in the hospital who were on telemetry from having a critical alarm go unnoticed and a serious problem potentially remain untreated.

Focus on the Patient

Cancer Treatment Centers of America,Eastern Regional Medical Center

Hannah Do, MD

Dr. Hannah Do observed that gastroenterology procedure times were inconsistent due to variations in operating room setup. She took the lead to work with surgery staff to ensure standardization of room setup and reduce procedure times.

Hannah Do, gastroenterologist and medical director of Total Parental Nutritional Services at Cancer Treatment Centers of America® at Eastern Regional Medical Center, is a key member of the medical center’s Patient Safety Committee.

From discussing serious safety events and making recommendations, to opening up discussions and reporting safety events, Dr. Do has improved patient care. She does not assign blame or make assumptions, but instead objectively reports the issue and then offers to become part of the solution.

For instance, Dr. Do observed that gastroenterology procedure times were inconsistent due to variations in operating room setup. To ensure that the operating room was ready as soon as the patient was, Dr. Do offered an in-service (education session) for the surgery staff to assist in standardizing operating room setup for gastroenterology procedures.

After the in-service, she reported that the staff were engaged, taking notes and asking questions. Dr. Do’s focus is always on the patient and on how she, as a patient safety professional, can deliver her clinical expertise in the safest and most efficient way possible. She is a leader in facilitating a culture of safety.

Innovation

UPMC Presbyterian Shadyside

Carol Mathews, BSN, RN; Cecilia Zamarripa, MSN, RN; Lisa Donahue, DNP, RN; Sarah Cua, MBA, MSN, RN; Kristian Feterik, MD

After finding that nasopharyngeal airway devices were being used as an alternative to body fluid management, which increased patient risk for harm, a nursing team utilized event reports to revise an existing facility policy. The policy addressed the utilization of the device, focused on patient assessment, and implemented nursing interventions for prevention of incontinence.

Nurses develop creative ways to manage their patients’ symptoms, especially when they involve bodily fluids such as diarrhea. The hospital found that nurses were using nasopharyngeal airway devices as off-label rectal trumpets to manage fecal incontinence. However, unintended problems developed, including patients experiencing rectal mucosal injury, bleeding, or perirectal injuries.

A team was convened with the goals of promoting best patient-care outcomes, eliminating serious events related to rectal injury, and more effectively managing diarrhea in hospitalized patients. The revised fecal containment policy now includes a focus on assessing reversible factors that lead to diarrhea and initiating nursing interventions to address those factors.

For example, dietitians are consulted to evaluate enteral feeding formulas to address the diarrhea. In addition, medical evaluation of the diarrhea is encouraged, including testing for infection.

When a fecal management system is ordered now, the wound, ostomy, and continence (WOC) nurse must assess the patient and rule as to whether a device can be used. The WOC nurse provides a detailed explanation to staff nurses with each case and a rationale if using the device is disallowed. The medical provider may override the WOC nurse’s refusal for the benefit of the patient. But the revised care protocol specifies that a formal patient consent must first be obtained and verified.

In the year before the revised policy and care protocol were implemented, there were 18 adverse fecal-containment-related events. The hospital had only a single adverse event in the eight months that followed.

Long-Term Care

Crosslands

Heather Kline, RN

As an infection control preventionist (ICP), Heather Kline’s involvement includes surveillance, reporting, regulatory compliance, education, development of an antibiotic stewardship program, and leadership at the Infection Control and Prevention meetings and Quality Assurance Performance Improvement Program.

Heather Kline began her employment with the long- term care community in 2007, as a per diem nurse in the skilled-care facility. She was hired as the full-time registered nurse assessment coordinator (RNAC) in 2010. Not only does she perform her RNAC duties in an exemplary manner, she serves in key roles in essential programs, including Corporate Compliance, Department Health Services, Department Policy Development, and the Infection Prevention and Control Program. Kline is the facility’s infection control preventionist (ICP).

In this role, Kline conducts surveillance and reporting and ensures that the facility’s infection and prevention control practices meet regulatory requirements. Further, she conducts staff, resident, and family education and provides leadership at the monthly Infection Control and Prevention meetings and the quarterly Quality Assurance Performance Improvement Program.

Kline has demonstrated her commitment to excellence by initiating certification as a long-term care ICP. Kline has been instrumental in developing an antibiotic stewardship program and in the facility’s participation in the Authority’s Antibiotic Stewardship Initiative.

When she’s not delighting the staff with homemade Christmas cookies, Kline is demonstrating her commitment to patient safety through her enthusiasm, energy, and passion.

Ambulatory Surgery

Shriner’s Hospital for Children

Erie Deborah Balogh, RN

As a patient safety officer, Debbie Balogh ensures that patients and their families are well prepared for surgery, and she helps with many patient safety efforts, such as review of medical records for completeness, development of a preoperative checklist and antibiotic stewardship program, and opioid management.

Debbie Balogh’s commitment to patient safety is evident in her role as the patient safety officer for the ambulatory surgery center, effectively leading its Patient Safety Committee. In her role as a nurse in the center’s Pre-op and Post-Anesthesia Care Unit (PACU) areas, Balogh ensures every patient and family are prepared for surgery. She reviews medical records for completeness, confirms patient and family understanding of preoperative education, and helps prevent any wrong-patient, wrong-procedure, or wrong-site surgery.

Hospital forms might seem like dry paperwork, but they drive patient care, and Balogh was involved in creating two important forms. The first is a preoperative checklist she helped develop for use before the patient enters the operating room (OR). It aims to ensure that preparations are performed, such as removing hair, administering prophylactic antibiotics and nerve blocks, and positioning the patient on the OR table.

The second is the “Peds Ortho Emergency Medication Sheet.” This sheet, used in pediatric emergencies, includes the patient’s medications, defibrillation attempts, IV boluses, and postoperative medications, and provides the patient’s weight the day of the procedure (important for weight-based medication dosing). Balogh provides education on this form to all new physicians, residents, fellows, and RNs.

Finally, she was involved in developing an antibiotic stewardship program for the center, including policy development; education for providers, staff, patients, and families; and monitoring of antibiotic use.

Individual Impact

Einstein Medical Center

Montgomery Raymond J. Cipollini

As part of an initiative for all staff to be responsive to patient needs, Raymond visits with patients and families following his response to call lights in order to, “take their mind off their troubles and make them smile,” recognizing that being a patient can be lonely.

Maintenance mechanic Raymond J. Cipollini is a longtime employee in the maintenance department whose work can involve repairs in patient rooms.

One day, a patient had activated the nurse call button, and before anyone else could respond, Cipollini entered the room, using the hospital’s AIDET introduction protocol (Acknowledge, Introduce, Duration, Explanation, and Thank You). He learned the patient needed help getting to the bathroom and found a nurse to assist. The next day, a senior leader heard a lively conversation coming from the same patient’s room.

After introductions, the leader asked if the patient and Cipollini were friends. They both responded, “Since yesterday!” Nurses told the leader that Cipollini excels in making a difference for patients.

"It’s lonely in those rooms... When I stop in, I hope I take their mind off their troubles and make them smile." Raymond Cipollini

For instance, he often intercepts patients who are fidgeting and trying to get out of bed or pulling at their IV lines, even before the fall alarm sounds. He circles back to check on patients with whom he spoke the day before.

Sports-fan patients like that Cipollini stops in to hear the score when a game is playing. Families say Cipollini’s visits are different from nurse visits, and help keep their minds in a positive place. Asked for his philosophy, Cipollini says, “It is lonely sometimes in those rooms, especially for our patients who do not have visitors. When I stop in, I hope I take their mind off their troubles and make them smile.”

These are the kinds of human connections and compassionate interactions that make a difference in patient care.

Video

UPMC Susquehanna - Williamsport

Melissa Furman, MSN, RN-BC; Becky Hess, MHA, MSN, NE-BC; Ellen Kramer, MSN, RN, NE-BC, ONC; Laura Fry, MSN, RN-BCy

To decrease patient falls, the multidisciplinary falls team created a baseball-themed video to show to each patient, at every admission, a sports commentator who educates patients about falls risk factors and interventions to prevent falls.

Hospital leaders were concerned that the falls rates on their inpatient units were consistently higher (worse) than the Veterans Health Administration (VHA) benchmark for falls per 1,000 patient-days.

A multidisciplinary falls committee was formed, and its members decided that what was missing was captivating educational materials for patients and families about falls, explaining the interventions used while patients are in the hospital’s care.

This education also needed to discuss risk factors leading to falls that one might not always think of—including receiving anesthesia or new medications and having to navigate a new environment—and the fact that a nurse must stay in the bathroom with all patients who are at risk for falling.

Many hospitals use the “Call, Don’t Fall” rhyme. The committee offered a further rhyme: “Play Ball!” A subcommittee wrote an encompassing and entertaining script with a baseball theme. A sports commentator provides the bulk of the education. More than 100 staff members viewed the video at a red carpet event in the cafeteria for the video’s debut.

Leaders were amazed to see the staff bond over the video, even singing the falls-prevention jingle (based on Anita Ward’s “Ring My Bell,” sung off-key with enthusiasm in the video) as they worked. The video is available on the facility’s patient-education platform, and every patient views it upon admission, which is automatically noted in the electronic medical record.

Since the video education was implemented, the hospital has drastically reduced its fall rates and now meets VHA benchmarks.

Best Use of Authority Resources

Chester County Hospital

Katie Costantini, MSN, RNC-MNN; Ann-Louise Jeffery, MSN, RNC-MNN; Jodi Levine, MD; Trish Ward, MSN, RNC-OB;Janeen Smith, BSN, RN; Liz Waterhouse, RNC-OB

In response to a statewide rise in infant falls, this multidisciplinary team used a systematic quality-improvement process to develop an infant safety bundle for the mother-baby unit after participating in an educational webinar by the Pennsylvania Patient Safety Authority.

Infant falls in the hospital can be devastating for both families and staff members as well as traumatizing or injurious to the infants.

In fiscal year 2016, three infant falls occurred on the Mother Baby unit. Staff on the Mother Baby unit set a goal to reduce infant falls by providing education to both staff and families.

After participating in a Patient Safety Authority webinar, a multidisciplinary team used a systematic quality-improvement process to develop an infant safety bundle for the Mother Baby unit. The group created a safety agreement to engage patients in keeping their families safe. Educational materials, such as safety posters and crib clings, were also introduced to reinforce learning.

The team produced its own infant safety video for families to view as part of their orientation to the unit. It is shown to all patients within the first four hours of admission. The video is also available to educate family members and friends via the hospital’s television network and website.

Feedback for the bundle has been positive with patients expressing appreciation and support. The infant safety bundle was implemented in July 2016 and the unit has had zero infant falls since its inception.

Improving Diagnosis

Executive Director’s Choice

UPMC Hamot

Michelle Nelsen, RN

A patient, who was previously seen for chest pain and had a negative cardiac work-up, started to develop entire body weakness. The patient was ultimately diagnosed with Lyme Disease after Michelle suspected and recommended testing because she was aware that Lyme Disease symptoms were “presenting differently” at that time.

A patient was first seen in the Emergency Department (ED) for chest and arm pain. He was evaluated for cardiac issues but all tests came back negative. The patient saw his primary care provider the next day.

Over the following weeks, he developed additional symptoms, and was seen by his primary care provider and in the ED multiple times. During another visit to the ED one month later, the patient’s symptoms had progressed. Michelle Nelsen, his nurse, suggested that he had an atypical presentation of a specific disease.

"If it weren’t for Michelle, I don’t think a diagnosis would have been found." Patient Relative

She presented her thoughts to the ED physician, who ordered testing, which confirmed Michelle’s suspicion. The patient was then treated for this condition. The patient’s wife said, “If it were not for [Michelle], I do not think a diagnosis would have been found.”

Nelsen, a senior nurse in the department, used her experience and expert assessment skills to drive the care of a patient. Her willingness to communicate with the ED team aided in the diagnosis that was long overdue for this patient. Her story is a prime example of why healthcare workers go to work every day—to help other people.

Note: Any included numbers and/or results were provided for publication by the recognized healthcare facilities. The Patient Safety Authority has not independently verified, and bears no responsibility or liability, for these numbers and/or results.

Patient Safety Advisory

Peer-Reviewed Journal Dedicated to Safety

The Patient Safety Advisory is a quarterly, peer-reviewed journal that highlights trending patient safety concerns and provides frontline staff tools for prevention and treatment. Topics span the care continuum and may reflect areas that are commonly reported, like falls, or they may address a single incident with the potential for wide-spread harm.

A Pennsylvania hospital reported that clinicians nearly failed to rescue a patient who had a heart attack because the patient had been mistakenly designated as “DNR” (do not resuscitate). The source of confusion was that a nurse had placed a yellow wristband on the patient, thinking that it signified “restricted extremity” (i.e., the arm should not be used for drawing blood or obtaining IV access), because that’s what yellow wristbands indicated at another facility where she worked.

She didn’t realize there was no standardized system for color-coded wristbands or that in this hospital, yellow signified patients who were DNR. Fortunately,someone identified the mistake and intervened. This Advisory article alerted others about the potential risk and sparked a national movement to standardize wristband color that now includes more than 40 states and the United States military. Readers from across the nation and dozens of countries abroad turn to the Advisory for stories like this to protect their own patients from harm.

5,000 Ways the Advisory Has Made Healthcare Safer

Each year, the Authority surveys PSOs about the Advisory feedback on past articles, suggestions for new topics, and whether they've incorporated any of its recommendations. Since the Advisory's inception, there have been almost 5,000 documented practice changes attributed to its content.

According to this year's annual PSO survey, facilities implemented several practice changes in response to one or more Advisory articles.

Revamp of the Surgical Timeout Process

Timeouts are a final safety check that occur just before starting a surgery or procedure.

Implementation of a Good Catch Recognition Program

Good Catch programs celebrate staff members who prevented harm.

Revision of Language and Process for Handoffs

Poor communication is consistently ranked among the top safety concerns nationwide.

Initiation of a Monthly Safety Check for Sterile Processing

Retained bioburden can put patients at an increased risk for infections.

Inclusion of Anti-Bullying Training in Facility-wide Education

Bullying is a silent epidemic that can lead to poor morale, depression, and suicide.

Development of a Standardized Count for Equipment in the OR

The most common retained foreign bodies during surgery include sponges and needles.

Infection Preventionists

Providing Facilities the Resources Necessary to Combat Healthcare-Associated Infections

There was a 58% decline in healthcare-associated infections in the U.S. between 2002 and 2011.^1,2 While this marks significant progress, there is still much work to be done with almost 2,000 individuals contracting an infection from a healthcare facility every single day.

While infections can be especially complex because of the nuances between pathogens and a mindfulness of antibiotic stewardship, the CDC found that facilities can experience a 70% reduction in some healthcare-associated infections (HAIs) when providers, nurses, and care teams are aware of infection prevention practices and implement evidence-based solutions.³

Because of this, the Authority has a dedicated team of Infection Preventionists (IPs) who provide healthcare facilities guidance on such practices for prevention and treatment.

The team is a resource for every healthcare facility in the Commonwealth, though much of their efforts focus on the long-term care (LTC) community, who identified reducing infections as a top priority during focus groups in the spring.

With antibiotic stewardship being such a key component of prevention, 31 LTC facilities joined a collaborative in September aimed at reducing unnecessary cultures and orders for antibiotics. The collaborative will continue through 2018 and seeks reduction targets of 10% for identified measures.

In 2017, the Authority provided training to more than 3,300 healthcare professionals on a broad range of topics, including early sepsis recognition, safe injection practices, and Legionella.

Per the CDC’s most recent HAI Progress Report, last updated in 2016, Pennsylvania was one of only three states that scored better than the national standardized infection ratio (SIR) and the national benchmark for CLABSI, CAUTI, MRSA, C. Difficile, and surgical site infections for colon surgery (the others being Oregon and Wisconsin).

2017 Infection Preventionist Highlights

Each of the Authority’s Infection Preventionists spoke at the annual conference for the Association for Professionals in Infection Control and epidemiology (APIC) in Portland, Oregon. Topics covered included reducing CAUTIs in LTC patients and early detection of sepsis.
JoAnn Adkins was accepted as an APIC fellow. She joined Terri Lee Roberts and Jim Davis who received the honor in 2016.
Terri Lee Roberts was appointed as a faculty member for APIC. Faculty members not only present course content but also provide mentorship to learners.
Jim Davis was named Research Chair for APIC after previously holding the position of Vice Chair.
Sharon Bradley spoke to 400 leaders in long-term care at the Pennsylvania Directors of Nursing Administration’s (PA- DONA) annual conference in Hershey.
Terri Lee Roberts was featured in the Certification Board of Infection Control and epidemiology’s (CBIC) weekly CIC^® in the Spotlight. This program recognizes the accomplishments of professionals Certified in Infection prevention and Control (CIC).
Sharon Bradley was elected to APIC of Delaware Valley and Philadelphia’s Board of Directors for the 11th time. She also served as Director and Chapter Legislative Representative.
Jim Davis conducted Ebola center assessments with DOH and HAP.
JoAnn Adkins and Sharon Bradley co-led a collaborative on antibiotic stewardship. Thirty-one LTC facilities began working together to achieve a 10% reduction in three main process measures.
Terri Lee Roberts was a facilitator for Allegheny County’s Antibiotic Stewardship Workshop for Acute Care and Long-term Care Facilities in June.
Sharon Bradley was approached by the Society for Post-Acute and Long- Term Care Medicine (AMDA) to present a workshop on infection in LTC facilities at their annual conference in Texas.

Healthcare-associated infections

Pennsylvania LTC Facilities

Analysis

Of the 700 facilities active as of December 31, 2017, validation criteria were met by 619 (88.4%). Eighty-one facilities were excluded because of the following criteria:

The number of resident days were not reported for one or more months during the year; 54 LTC facilities were excluded from 2017 data analysis, compared to eight in 2016.
Occupancy for one or more months was above 100% or below 50%. In 2017, 25 LTC facilities were excluded, compared to 16 in 2016.
In 2017, two LTC facilities were excluded from unit level analysis for not reporting resident days at the unit level, compared to one in 2016.

For the annual comparisons displayed in the figures, rates were calculated based on the appropriate denominator for each infection type. Confidence intervals for these rates were calculated by multiplying the standard error by 1.96 to approximate 95% confidence.

Urinary Tract Infection (UTI)

Mixed units and ventilator-dependent units exhibited statistically significant increases in catheter-associated urinary tract infection (CAUTI) compared to rates in 2015. No statistically significant changes were evident in the other units.

Skilled nursing/short-term rehabilitation (SN/STR) units demonstrated a statistically significant increase in symptomatic urinary tract infection (SUTI) rates compared to 2015.

SN/STR units demonstrated a statistically significant increase in device-related asymptomatic bacteremic urinary tract infection (DR-ABUTI) compared to 2015, and dementia units showed a statistically significant increase in non-device related ABUTI compared to 2015.

ABUTI signals the conversion of asymptomatic bacteriuria into bacteremia or sepsis. Even if rates are low, ABUTI should remain a focus because these bloodstream infections can be fatal.

Skin and Soft Tissue Infection

Rates of cellulitis remained constant throughout the defined care areas, which is consistent with 2015 and 2016 (Figure 6). Scabies and conjunctivitis occurred in all care areas, but ventilator-dependent patients seemed to experience more conjunctivitis and cellulitis.

Central Line-Associated Blood Stream Infections (CLABSI)

CLABSIs are divided into three categories: dialysis lines, temporary lines, and permanent lines. The definition for each line type appear in Table 3. When CLABSI rates are very low, even zero, there may still be infections, i.e., when the median rate per 1,000 central line days is 0, it does not necessarily mean that there no infections occurred.

The Authority encourages facilities to assess practices related to the care and maintenance of central lines, adhere to accepted clinical standards, and engage dialysis centers in conversations about care and maintenance of dialysis lines.

Respiratory Tract Infection

There was statistically significant variability in the rate of influenza from 2015 to 2017. The cause of this variability was likely multi-factorial, including seasonality, vaccine effectiveness, pathogen virulence, and vaccine uptake. All units except the ventilator-dependent units had significant decreases in influenza rates from 2015 to 2016, followed by significant increases from 2016 to 2017.

The rate of influenza-like illness (ILI) mimicked the statistically significant decrease in rates of Influenza from 2015 to 2016 except for the ventilator-dependent units. Between 2016 and 2017, the only statistically significant increase in ILI was noted in the mixed units.

The ventilator-dependent units showed a statistically significant increase in the rate of pneumonia from the 2015 baseline rate to 2016 and a trend toward further increase in the rate in 2017.

Gastrointestinal Infection

Gastrointestinal infections in 2017 were primarily attributed to Clostridium difficile (C. diff) and norovirus. A norovirus outbreak is defined as three or more cases of norovirus identified within a three-day period.

Patient Safety Authority impact

Pennsylvania. United States.

Two and a half years before the Patient Safety and Quality Improvement Act was signed into federal law, the Patient Safety Authority was founded to improve the quality of healthcare in Pennsylvania. Three employees accepted a seemingly unachievable challenge: Define patient safety, develop a system to track it, and foster a reporting culture across 1,200 facilities.

Fifteen years later, the Authority has surpassed all expectations. While staying true to its mission of preventing harm across the Commonwealth, the Authority has emerged as a trusted leader in patient safety nationally and abroad. In 2017 alone, almost 13,000 individuals attended an education session. More than 4,000 people worldwide read the Patient Safety Advisory, and Authority staff spoke at thirteen national conferences. Thanks to these efforts, healthcare facilities have been saving hundreds of lives and millions of dollars every year.¹

The Authority’s success has come from its willingness to adapt to the ever-shifting healthcare environment. Frontline providers are facing increasing demands, sicker patients, and fewer resources. Rather than expecting them to conform to traditional paradigms, the Authority transformed its offerings to maximize its effectiveness while minimizing time requirements. Webinars, social media, and mobile-friendly content are used routinely to provide life-saving information at the bedside.

With innovation as a core value, the Authority will continue to revolutionize patient safety and advance healthcare across Pennsylvania, the United States, and the world.

1. Pa Pat Saf Advis 2016 Dec;13(4):125-136.

Collaboratives - Antibiotic Stewardship, Anesthesiology, & HIIN

Antibiotic Stewardship

Evidence shows that antibiotics are some of the most commonly ordered but misused medications in nursing homes, with 40 to 75% prescribed without the presence of a bacterial infection.

To remedy this, infection preventionists from the Authority partnered with 31 LTC facilities across Southeastern and Southcentral Pennsylvania to develop, implement, and sustain an antibiotic stewardship program.

Through this collaborative, facilities receive personalized on-site consultation, access to a webinar series, monthly coaching calls, and robust data analysis.

The goals of this program are to achieve an overall 10% decrease in:

Urine cultures and antibiotics ordered for asymptomatic bacteriuria
Urinary tract infections (UTIs) that are treated with antibiotics but do not meet clinical criteria for a UTI
Urine cultures performed and new antibiotic orders for UTIs

This 15-month collaborative began in September 2017. The first three months (September through November) consisted of on-boarding participants and collecting baseline data. December 2017 through August 2018 marks the implementation phase, with an additional three-month phase for sustainability.

Wrong-site Anesthesia Nerve Blocks

From July 1, 2004 to December 31, 2016, wrong-site nerve blocks comprised 25.9% of all wrong-site procedures reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS). This percentage is notable given that only a fraction of patients who are vulnerable to wrong-site surgery receive anesthesia in the form of blocks. The Authority partnered with the Pennsylvania Society of Anesthesiologists for the following:

To evaluate current practices for preventing wrong site/side blocks through interviews with expert panel members and stakeholders including, anesthesiologists, surgeons, nurses, and patient respresentatives
To conduct a systematic literature review that will be used as a knowledge base for developing a guidance document
To draft and disseminate guidance and resource document(s) to address wrong-site/side regional anesthesia block prevention for physicians, nurses, and healthcare facilities.

Hospital Improvement Innovation Network (HIIN)

The Authority continued its partnership with the Hospital and Health system Association of Pennsylvania (HAP) for the Hospital Improvement Innovation Network (HIIN) under contract with CMS. The goals of the HIINs are to achieve a 20% decrease in overall patient harm and a 12% reduction in 30-day readmissions from the 2014 baseline.

The Authority managed three focus areas: 1) adverse drug events (ADE), 2) injury falls and immobility, and 3) culture of safety.

At the end of September, the Authority transitioned management for reducing Emergency Department (ED) radiologic diagnostic error to the Health Care Improvement Foundation (HCIP), but maintained active involvement.

ADVERSE DRUG EVENTS

Adverse drug events include medication errors or unexpected reactions. Resources provided to these participating organizations included:

Education opportunities such as webinars and one-on-one coaching calls
Tip sheets developed to reinforce methods for data collection, reporting, and outcome measurement
Project-specific outcome and process measures worksheet
Newsletters from the Institute for Safe Medication Practices and relevant journal articles

Falls

One of the most commonly reported serious events by Pennsylvania hospitals are patient falls with injury. Participants in this collaborative received:

Patient Safety Authority post-fall investigation tool, self-assessment, subsequent action plan, point prevalence audits
Networking regional meetings, webinars, coaching calls, on-site consultation
Data analysis and trend identification
Facility needs assessment

CULTURE OF SAFETY

A culture of safety is the foundation for reducing harm and proving the quality of care. This collaborative was open to all HAP HIIN enrolled facilities. Resources provided to participants included:

Participation in a safety leadership simulation managed by the Johns Hopkins University School of Medicine
Collaboration with Person and Family Engagement for shared learning opportunities
Partnership with the American Institute of Researchers and the Institute for Patient and Family Centered Care to develop a pre-admission patient checklist

DIAGNOSTIC ERROR

Reducing diagnostic error is an emerging area of study and continues to be a focus for the Authority. Participants received:

Webinars and on-site consultation
Establishment of a multidisciplinary stakeholder meeting with participants including radiologists, technologists, emergency medicine physicians, nurses, and executive leadership
Development of a process to identify and measure diagnostic errors
Selection of measurable targets, including two process measures and one outcome measure, with analysis that began in November 2017

MEDICATION SAFETY-Preventing Error in Outpatient Pharmacies

Outpatient pharmacies exist in a variety of settings, including entities affiliated with or located within hospitals, health systems, and clinics, as well as freestanding pharmacies. These pharmacists provide a variety of services to the community, including dispensing prescriptions, administering immunizations, providing medication-therapy management, providing patient education, and making recommendations for over-the-counter medications.

When dispensing medications, pharmacists perform tasks that can be repetitive, yet require high levels of training and optimal performance under considerable time constraints. Dispensing a prescription can involve more than 40 separate steps. Combine this with the distractions from telephones, emails, customers, and supervising technicians, and a system emerges that is perfectly positioned to facilitate errors at any step in dispensing process.

The outpatient pharmacy setting provides a unique problem where errors might go unnoticed for a significant period of time. Patients usually receive a 30- to 90-day supply of a prescription, which may cause them to take an incorrect therapy or dose for months. Potentially serious outcomes could occur as a result.

Analysis & Prevention Strategies

Analysts reviewed medication errors that occurred in outpatient pharmacy settings. Of the 1,044 errors, the top three event types were wrong drug (19.6%), incorrect medication list (17%), and wrong dose/overdosage (14.7%).

One of the key differences that was identified from an inpatient pharmacy was that once an error occurred in an outpatient setting, fewer clinicians handled the medication and could catch an error before it reached the patient. The final dispensed prescription was in the control of the patient rather than a nurse or healthcare practitioner.

In response, the team developed risk reduction strategies to prevent as many potential errors as possible before a medication reaches the patient. Some examples include:

When searching for a drug in the pharmacy computer system during order entry, type the drug name using at least the first four or five letters and its strength.
Implement barcode scanning to identify when the wrong product is selected from the shelf. Conduct audits to review compliance.
Employ technological solutions that require the pharmacy to ask for the patient’s date of birth.
Open the prescription bag and have the patient review the labels and contents of each prescription to verify that the medication is correct.
Educate patients by using scripts and checklists, especially for high-alert medications. This should include a discussion of the medication’s purpose to help ensure the correct medication is being dispensed to the correct patient.
Develop a continuous quality improvement program to enhance safety, identify and evaluate incidents, and enhance the efficiency and effectiveness of quality-related infrastructure.

Standardization - Pressure Injury Reporting

More than 2.5 million people develop a pressure injury each year in the United States, with almost 60,000 dying as a direct result. Costs for treatment range from $20,900 to $151,700 per pressure injury, with annual estimates totaling between $9.1 and $11.61 billion.

Though pressure injuries are an expensive, life-threatening condition, existing reporting practices varied widely among Pennsylvania facilities

Pressure injuries are classified by their severity, or “stage”, ranging from Stage 1 (least severe) to Stage 4 (most severe). Stage 3 and 4 pressure injuries typically require specialized treatment, such as a consult from wound care nurses, and may place patients at an elevated risk of infection. Despite this, 80% of hospital-acquired Stage 3, 4, unstageable, and deep tissue injuries were being reported as incidents and not a serious event.

Additionally, 50% of reports related to pressure injuries were for those present on admission (POA), though only pressure injuries that occurred during a patient stay must be reported. Twenty percent of acute care hospitals weren’t reporting any pressure injuries, though it was unlikely that there were no incidents over the course of a year. These erratic and insufficient reporting practices made analyzing trends and developing prevention strategies difficult.

As such, the Authority and its Board of Directors identified standardization of pressure injury reporting as a priority. Collecting consistent and standardized reports of healthcare-acquired pressure injuries would allow the Authority to better understand the impact they have on patients and assist healthcare facilities with their prevention.

A draft guidance document was published in the Pennsylvania Bulletin 46 Pa.B. 6198 on October 1, 2016. Fifteen organizations provided feedback during the public comment period. The Authority, in collaboration with the Pennsylvania Department of Health (DOH), revised the reporting guidelines reflective of their comments.

A final guidance document was approved and published in the Pennsylvania Bulletin 47 Pa.B. 2163 on April 8, 2017. The final guidance went into effect on January 1, 2018 and contained five main reporting principles and a decision tree to assist healthcare facilities in reporting determinations.

Acute Care data

Pennsylvania Patient Safety Reporting System (PA-PSRS)

PA-PSRS is a secure, web-based system for healthcare facilities to submit reports confidentially. No patient or provider names are solicited, and no information about individual facilities is made public.

Reporters answer 22 core questions, including patient demographics, level of harm, if any, and event type. The report also collects details about “contributing factors,” such as staffing, clinical protocols, and the impact of health information technology (HIT). Users are asked to identify the root causes of serious events and to suggest procedures that can be implemented to prevent a recurrence.

Analysts review hundreds of thousands of event reports each year and alert healthcare facilities about any concerns and potential methods for prevention.

Additionally, the Authority developed robust analytics within PA-PSRS that allow each facility to assess their own data in real-time.

This section includes only reports of serious events and incidents. Although PA-PSRS collects information about infrastructure failures and any additional items (other), those reports are submitted only to the Department of Health. (See below.)

Interpreting PA-PSRS Data

Several factors influence the number of reports submitted by a particular facility, of which each facility’s safety and quality are just two.

Other factors include facility size, case volume, services provided, patient case mix, severity of illness, understanding of what is reportable, and success in detecting reportable events. The following factors should be considered when reviewing PA-PSRS data:

PA-PSRS has its own unique definitions for what is reportable. Because it uses a specific taxonomy of event types that may differ from other systems, it may be difficult to draw direct comparisons.
Data is based on reports submitted through PA-PSRS between January 1, 2017 and December 31, 2017 (unless otherwise noted).
The data is not adjusted to reflect facility openings, closings, or ownership changes. Unless otherwise noted, report counts are actual “raw numbers” and have not been adjusted for any facility- or patient-related factors.
Broad explanations of why some event types predominate in aggregate data are complex, especially because each event type may relate to numerous and diverse clinical situations.

Reports by Event Type

PA-PSRS uses a taxonomy designed to answer the most basic question about an occurrence: “What type of event happened?” The complete event-type taxonomy is a three-level, hierarchical taxonomy with 222 distinct event types.

Events types are divided into second- and third-level subcategories. For example, the category “Falls” includes a series of subcategories such as:

Falls while Lying in Bed
Falls while Ambulating
Falls in the Hallways of the Facility
Other Types of Falls

Although errors related to procedure/treatment/test (EPTT) was the most commonly reported event type, it was not the one most often associated with patient harm, complications of procedure/treatment/test (CPTT) accounted for more than half (52%) of the serious events submitted in 2017.

CPTT has historically had the largest percentage of serious events with respective rates of 54% and 53% in 2015 and 2016. EPTT had the largest increase in number, 6,145 more reports than in 2016, a 8.3% increase. This equates to 38% of the total report submission increase in 2017.

Control Charts – How Do You Show Change Over Time?

How do you know if changes that occurred over time happened by chance or were expected? One way to measure variation is with control charts: statistical models that take into account all known causes of variability to determine if a true impact occurred.

You take the subway each morning to head to class. Your commute normally lasts between 10–15 minutes, depending on how many people enter or exit at each stop.

One day, the engine experiences an electrical problem, and it takes you 26 minutes to get to school. Just because your commute was longer than usual on that one day, there’s no reason to assume that it will continue to be longer in the future.

However, if your subway line is overly crowded and the city plans to build another station on your line, you should expect that this extended travel time will persist.

The same variability can happen with event reporting. By using control charts, we can assess whether the number of event reports increased in a given year because more events occurred, or if, perhaps, the culture of safety is improving and people are more apt to report something than they were before.

Reports by Facility Type

There was an increasing percentage of reports from non-hospital acute-level facilities (e.g., ambulatory surgical facilities, birthing centers, and abortion facilities [ASFs/BCs/ABFs]) compared with hospital reports from 2005 to 2017.

Reports by Level of Patient Harm

Healthcare facilities apply a 10-item scale to each report to measure whether an event “reached” the patient and, if so, how much harm it caused. This scale ranges from “unsafe conditions” (e.g., look-alike medications stored next to one another) to the death of the patient.

While CPTT comprises 13.8% of all reports in 2017, it comprises 52.5% of the reports of events involving harm, including those resulting in or contributing to the patient’s death. Examples of CPTT include:

Pneumothorax following surgery or invasive procedure—56.4% involved harm
Wound dehiscence following surgery or invasive procedure—51.3% involved harm
Unplanned transfer to ICU following surgery or invasive procedure—46.1% involved harm

At the other end of the spectrum, although medication errors comprise 17.9% of reports in 2017, they comprise only 2.6% of reports involving harm and 2.4% of reports of events contributing to or resulting in death.

Harm score A is intended to identify “unsafe conditions” (i.e., there was an observed situation or hazard), and patient harm was a possibility if corrective action was not taken. EPTT was the event type where unsafe conditions were most often reported (48.3%).

The event type in which unsafe conditions were least frequently reported was adverse drug reactions (ADR). Of all ADR events, 0.2% were reported as unsafe conditions. Falls (0.9%) and self-harm (1.1%) each accounted for about 1% of submitted reports of unsafe conditions.

Harm scores of E through I are considered serious events, because a patient experienced some level of harm. Harm scores of G, H, and I are deemed high harm events because they are associated with permanent harm or death.

Patient Demographics: Age and Gender

Patient disparity data is limited to gender and age because the Authority is not authorized to collect individually identifying information.

Event Type and Gender

The proportion of reports involving female patients was greater than 60% among reports of ADR and self-harm. The three event types involving a greater proportion of male patients in 2017 included equipment issues, falls, and skin integrity reports.

Age Cohorts - Neonatal Patients

In all, 9,602 reports involved neonatal hospital patients (those aged 20 days or younger), an increase of 1,072 reports (12.3%) from 2016. Less than 2% (1.3%) of neonatal reports were classified as serious events, noticeably lower than the overall serious event percentage of 2.9% for 2017. More than two-thirds (68.3%) of reports for neonatal patients were related to events of EPTT. Because of specialized needs based on age and size, these patients are proportionally more likely to experience errors or complications.

About one-sixth (16.8%) of reports involving neonatal patients were related to medication errors. There is a slight but consistent decline in the percentage of reports involving medication errors since 2005 for this age cohort. CPTT accounted for 74.4% of the serious events in this age group, which was somewhat higher than for this event type in 2016 (73.3%).

Eighty percent are neonatal complications, such as birth injury or trauma (n=44), other (n=12), unplanned transfer to the neonatal intensive care unit (NICU; n=6) and Apgar score <5 at 5 minutes (n=6). Apgar score is a method to quickly summarize the physical condition of a newborn. Measures include heart rate, muscle tone, and skin coloration.

Age Cohorts - Patients 65 or Older

These patients account for 38.5% of hospital reports in 2017, 2.5% less than in 2016. Some highlights include:

Since 2014, fewer than 50% of reported falls have involved patients 65 or older.
Hospital patients 65 or older accounted for 71.2% of skin integrity reports, including pressure injuries, in 2009. This figure fell to 63.7% in 2017.

The decline in pressure injury reports may reflect the effect of standardization and exclusions in reporting (i.e., “It is not necessary to report a serious event that occurred in another healthcare setting”).

Age Cohorts - Children and Adolescents

52,965 reports involved children and adolescents (i.e., patients younger than 21 years) in hospitals. This total is 13.5% higher compared to 2016. The top two report types were EPTT (accounting for 35.0% of the reports of this population), and medication errors, at 30.0%. CPTT made up 47.7% of the 457 serious events for this age group.

Reports by Location/ Department (Hospitals)

PA-PSRS has 155 designated care areas for hospitals that indicate the locations or departments in which a patient receives or is exposed to care.

The care areas designated as Critical Care and general medical/surgical units represented the greatest number of overall reports submitted in 2017, each generating nearly one-fifth of the total.

Other hospital locations with high report rates were Pediatrics, Surgical Services, and intermediate units. Although most hospital reports were submitted from Critical Care and general medical/surgical units, the greatest number of serious events came from Surgical Services, accounting for nearly one-third of serious events.

However, the care areas with the highest proportion of serious events per submitted report were Diagnostics/Lab and Surgical Services.

Reporting Trends

Depicting the volume of serious events and incidents on a relative scale (25:1) shows that the volume of serious events has increased somewhat over the long term, but not as sharply as the volume of incidents.

Reports Involving the Patient’s Death

Reports involving events that may have contributed to or resulted in the patient’s death (harm score I) account for fewer than 0.09% (i.e., about one tenth of one percent) of all submitted reports. In 2017, there were 246 reports of events that had a harm score of I, a 12.8% increase from 2016.

Despite this increase, the general trend still shows a decreasing number of patient deaths since 2005. The majority of reports involving a patient’s death are associated with CPTT. Although only 15% of all reports in 2017 were attributed to CPTT, 56.5% of all reports about patient death were related to a complication.

Of the reports involving death associated with complications, the majority describe patients who died after surgery or another invasive procedure (38.1%), with the next highest percentages reported as patients who suffered cardiopulmonary arrest outside the intensive care unit (ICU) setting (14.4%) and other complications (8.6%).

Summary

The data presented in this section suggest that healthcare facilities in the Commonwealth continue to make progress in their efforts to identify and report patient safety events. The increased reporting may suggest earlier recognition and proactive mitigation of hazards with fewer events reaching the patient and causing serious harm.

Geographic Profiles

PA-PSRS Data by Region

For this report, Pennsylvania was divided into six regions based on DOH’s Public Health Districts. The differences in events reported by region may be explained by noting variation of reporting patterns, i.e., more reports may be submitted in regions with larger populations and greater numbers of healthcare facilities.

However, Figure 17 shows that when factoring in the volume of care, hospitals in the Northwest and Southcentral regions reported the highest number of incidents per 1,000 patient days.

Many factors contribute to reporting variation. It would be speculative to consider facilities in any of the regions as more or less safe than those in other regions based solely on this data. The data is also not risk-adjusted. Larger numbers of reports may mean that the healthcare providers in certain facilities or regions were better at identifying and reporting potential patient safety issues.

Definitions

Key Terms Contained within This Report

ABORTION FACILITY

Act 30 of 2006 extended the reporting requirements in the Medical Care Availability and Reduction of Error (MCARE) Act to abortion facilities that perform more than 100 procedures per year. At the end of 2017, Pennsylvania had 19 qualifying abortion facilities.

ADVERSE EVENT

This term also appears in this report, although it is not defined in the MCARE Act. The Institute of Medicine Committee on Data Standards for Patient Safety defines an adverse event as follows: “An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.” The Authority considers this term to be broader than “medical error,” because some adverse events may result from clinical care without necessarily involving an error. Although PA-PSRS includes reports of events that result from errors, the Authority’s focus is on the broader scope of actual and potential adverse events, not only those that result from errors.

AMBULATORY SURGICAL FACILITY

The Health Care Facilities Act (HCFA) defines an ambulatory surgical facility (ASF) as “a facility or portion thereof not located upon the premises of a hospital which provides specialty or multi-specialty outpatient surgical treatment.

ASF does not include individual or group practice offices of private physicians or dentists, unless such offices have a distinct part used solely for outpatient treatment on a regular and organized basis. …Outpatient surgical treatment means surgical treatment to patients who do not require hospitalization but who require constant medical supervision following the surgical procedure performed.” At the end of 2017, there were 309 qualifying ASFs in Pennsylvania.

ANALYST

The analyst is a member of the Authority team with education and experience in medicine, nursing, pharmacy, product engineering, statistical analysis, and risk management. Analysts review events submitted through PA-PSRS and compose the majority of the articles included in the Patient Safety Advisory.

BIRTHING CENTER

The HCFA defines a birthing center as “a facility not part of a hospital which provides maternity care to child-bearing families not requiring hospitalization. A birth[ing] center provides a home-like atmosphere for maternity care, including prenatal labor delivery and postpartum care related to medically uncomplicated pregnancies.” At the end of 2017, Pennsylvania had six qualifying birthing centers.

HOSPITAL

The HCFA defines a hospital as “an institution having an organized medical staff established for the purpose of providing to inpatients, by or under the supervision of physicians, diagnostic and therapeutic services for the care of persons who are injured, disabled, pregnant, diseased, sick or mentally ill or rehabilitation services for the rehabilitation of persons who are injured, disabled, pregnant, diseased, sick or mentally ill. The term includes facilities for the diagnosis and treatment of disorders within the scope of specific medical specialties, but not facilities caring exclusively for the mentally ill.” At the end of 2017, Pennsylvania had 238 qualifying hospitals.

INCIDENT

An event which either did not reach the patient “near miss” or an event that did reach the patient but in which the level of harm did not require additional healthcare services. The legal definition from the MCARE Act: “An event, occurrence or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient. The term does not include a serious event.”

INFRASTRUCTURE FAILURE

A potential patient safety issue associated with the physical plant of a health-care facility, the availability of clinical services, or criminal activity. The legal definition from the MCARE Act: “An undesirable or unintended event, occurrence or situation involving the infrastructure of a medical facility or the discontinuation or significant disruption of a service which could seriously compromise patient safety.” Infrastructure failures are submitted only to the Pennsylvania Department of Health (DOH) and are not addressed in this report.

MEDICAL ERROR

This term is commonly used when discussing patient safety, but it is not defined in the MCARE Act. The word “error” appears in PA-PSRS and in this report. For example, one category of reports discussed is “medication errors.” The Institute of Medicine’s Committee on Data Standards for Patient Safety defines an error as the “failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning)…. It also includes failure of an unplanned action that should have been completed (omission). ”Within the MCARE Act, the term “medical error” is used in section 102: “Every effort must be made to reduce and eliminate medical errors by identifying problems and implementing solutions that promote patient safety.” It is also used in defining the scope of chapter 3, “Patient Safety”: “This chapter relates to the reduction of medical errors for the purpose of ensuring patient safety.”

NURSING HOME

Act 52 of 2007 revised the MCARE Act to require nursing homes to report healthcare-associated infections (HAIs) to the Authority. Specifically, the act states that “the occurrence of a health care-associated infection in a health care facility shall be deemed a serious event as defined in section 302.” Reporting from these facilities began in June 2009. For this report, Pennsylvania had 703 qualifying nursing homes at the end of 2017.

OTHER EVENT TYPE

The Centers for Medicare and Medicaid Services (CMS) requires hospitals to report to DOH any death of patients in restraints or in seclusion or in which restraints or seclusion were used within 24 hours of death (other than soft wrist restraints).

Deaths in which the restraints or seclusion are suspected of or confirmed as having played a role in the death should be reported as serious events. Other deaths in which the restraint or seclusion use was incidental or not suspected should be reported under this “Other” category.

Reports of serious events and incidents are submitted to the Authority for the purposes of learning how the healthcare system can be made safer in Pennsylvania. Reports of serious events and infrastructure failures are submitted to DOH so it can fulfill its role as a regulator of Pennsylvania healthcare facilities.

PATIENT SAFETY LIAISON

The patient safety liaison (liaison) is a unique resource to Pennsylvania MCARE facilities. Serving as the face of the Authority, the PSL provides education and consultation to MCARE facilities and ensures that facilities are aware of the resources available to them through the Authority, such as educational toolkits, presentations, and webinars. The program has eight liaisons located regionally throughout Pennsylvania.

PATIENT SAFETY OFFICER

The MCARE Act requires each medical facility to designate a single individual to serve as that facility’s patient safety officer (PSO). In addition to other duties, the MCARE Act requires the PSO to submit reports to the Authority.

SERIOUS EVENT

An adverse event resulting in patient harm. The legal definition from the: “An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. The term does not include an incident.”

STANDARDIZATION

Twenty-eight guiding principles went into effect on April 1, 2015 to improve consistency in event reporting through PA-PSRS. The guidance was developed to help provide consistent standards to acute healthcare facilities in Pennsylvania in determining whether occurrences within facilities meet the statutory definitions of serious events, incidents, and infrastructure failures as defined in section 302 of the MCARE Act.

The Authority, DOH, and healthcare facility staff have worked together toward a shared understanding of the requirements. The reporting guidelines were identified based on frequently asked questions (FAQs), controversies, and inconsistencies that were evident in the data collected by the Authority and DOH.

Department of Health Recommendations

The MCARE Act calls upon the Authority to suggest recommendations for statuary or regulatory changes that may help improve patient safety Pennsylvania. In 2017, the Board had no formal recommendations for any such changes. However, the Authority continues to work in partnership with DOH to standardize reporting requirements. (See Standardization.)

Referrals to Licensure Boards

The MCARE Act also requires that the Authority identify referrals to licensure boards for failure to submit reports under the Act’s reporting requirements. MCARE specifies that it is the medical facility’s responsibility to notify the licensee’s licensing board of failure to report.

No such situations were reported to the Authority during 2017. However, the Authority is unlikely to receive information related to a referral to licensure board because PA-PSRS reports do not include the names of individual licensed practitioners.

Anonymous Reports

The MCARE Act includes a provision that permits individual healthcare workers to submit what the act defines as an “anonymous report.” Under this provision, a healthcare worker who has complied with section 308(a) of the act may file an anonymous report regarding a serious event.

The form is available on the Authority’s website and through the PA-PSRS system. The Authority developed an “Anonymous Reporting” guide to ensure healthcare workers are aware of their option to submit an anonymous report and encourages them to do so when they believe their facility is not appropriately reporting or responding to a serious event.

Liaisons also review the anonymous reporting process with new PSOs as part of their onboarding program. Individuals completing the form do not need to identify themselves, and the Authority assigns professional clinical staff to conduct any subsequent investigations. In 2017, the Authority received seven anonymous reports that complied with MCARE Act requirements.

Fiscal Statements & Contracts

The MCARE Act establishes the Patient Safety Trust Fund (Trust) as a separate account in the Pennsylvania Treasury. Under the MCARE Act, the Authority determines how those funds are used to effectuate the patient safety provisions of the Act and administers funds in the Trust. Funds mainly come from assessment surcharges made by DOH on certain medical facilities.

The Authority recognizes that Pennsylvania hospitals, birthing centers, ASFs, abortion facilities, and nursing homes bear financial responsibility for costs associated with complying with mandatory reporting requirements. Accordingly, the Authority has focused on two fiscal goals: (1) to be prudent in the use of moneys contributed by the healthcare industry, and (2) to assure that healthcare facilities paying for PA-PSRS receive direct benefits from the system and from Authority programs in return.

Pursuant to Section 304(A)(4) of the MCARE Act, as a general rule, the Authority is authorized to receive funds from any source consistent with the Authority’s purposes under the Act. As such, the Authority at times contracts with and receives funding from other healthcare-related entities to reduce medical errors and promote patient safety in the Commonwealth. These contracts in 2017 are described in the section, “Contracts under which the Authority Received Revenue in 2017 as a Contractor,” which lists contracts with HAP and HCIF.

Funding from Hospitals, Birthing Centers, ASFs, & Abortion Facilities

The MCARE Act set an initial limit of $5 million on the total aggregate assessment on acute-care facilities for any one year beginning in 2002, plus an annual increase based on the consumer price index (CPI) for each subsequent year. For FY 2017–2018, the maximum allowable acute-care assessment is $7,206,856, against the Authority Board’s approved aggregate acute-care assessment of $6,860,000.

On December 12, 2017, the Authority Board authorized a recommendation to DOH for FY 2017–2018 acute-care assessment surcharges of $6.86 million. This amount is $185,000 or a 2.77% increase over the FY 2016–2017 acute-care assessment, and is 4.6% less than the maximum annual amount that could have been assessed for the year pursuant to Section 305(d) of the MCARE Act.

Beginning in 2015, the Authority Board authorized the use of the Northeast Medical Professional Services CPI to calculate annual adjustments to maximum assessments. At the time of this acute-care assessment recommendation, the Authority Board considered several points, including the following:

The Authority’s FY 2017–2018 budget totals $8.60 million. Of this amount, approximately $7.40 million is budgeted for acute-care related expenditures, funded in-part by the $6.86 million in FY17-18 acute-care assessments.
The Authority’s FY 2017–2018 budget of $8.60 million increased by $75,000, or 0.88%, from the previous fiscal year budget.
The FY 2017–2018 acute-care assessment of $6.86 million increased by $1.86 million since the Authority’s initial FY 2002–2003 acute-care assessment of $5.0 million, a 2.48% per year average increase. Since the Authority’s FY 2007–2008 acute-care assessment of $5.4 million, the acute-care assessment has increased by an average of 2.70% per year.

Also considered in authorizing this increase were staff and program growth, increases in Commonwealth of Pennsylvania mandated burdened benefit rates, and projected contract revenue in FY 2017–2018.

Table 1 shows the number of acute-care facilities assessed, approved assessments, and assessments received for each fiscal year.

Table 1 Acute Facility Assessments

a. The number of facilities assessed by the Department of Health differs from the number of the Medical Care Availability and Reduction of Error (MCARE) Act’s facilities cited elsewhere in this report because of differences in the dates chosen to calculate the number of facilities for these two different purposes.

b. Amounts assessed and amounts received differ because a few facilities may have closed in the interim or are in bankruptcy. In a few cases, the Department of Health has pursued action to enforce facility compliance with the MCARE Act’s assessment requirement.

c. 2017-18 missing figures were unavailable at the time of publication and will appear in next year’s annual report.

Table 2 Nursing Home Assessments

a. FY 2017-2018 missing figures were unavailable at the time of publication and will appear in the next year’s annual report.

Funding from Nursing Homes

Act 52 of the MCARE Act allows DOH to assess Pennsylvania nursing homes up to an aggregate amount of $1 million per year for any one year beginning in 2008, plus an annual increase based on the CPI for each subsequent year. In 2008, following the Authority’s suggestion, the Department assessed 725 nursing home facilities a total of $1,000,000 and transferred $1,000,782 to the Trust for FY 2008–2009. This money could be spent only on activities related to HAI and implementation and maintenance of Chapter 4 of the MCARE Act. For FY 2017–2018, the Act 52 maximum allowable assessment is $1,163,510, against the Authority Board’s approved ag gregate assessment of $1,140,000.

On December 12, 2017, the Authority Board authorized a recommendation to DOH for FY 2017–2018 nursing home assessment surcharges of $1.14 million. This amount is $29,000 more than the previous year’s assessment and is approximately 2.0% below the maximum assessment permitted under Act 52, based on annual CPI adjustments. Beginning in 2015, the Authority Board authorized the use of the Northeast Medical Professional Services CPI to calculate annual adjustments to maximum assessments.

Annual Expenditures & Revenue

Patient Safety Authority Contracts

The MCARE Act requires the Authority to identify a list of contracts entered into pursuant to the Act, including the amounts awarded to each contractor. During calendar year 2017, the Authority received services under the following contracts (FC, funds commitment; PO, purchase order).

ECRI Institute, FC # 4000018888

Contract for program administration, clinical analysis, training and data collection, and reporting infrastructure services.

Contract total: $24,227,233 over 4 years and 9 months from October 2014 to June 2019.

Amount invoiced for 2014: $1,135,983.79 (Oct. through Dec.)

Amount invoiced for CY2015: $4,824,833.20

Amount invoiced for CY2016: $4,947,215.02

Amount invoiced for CY2017: $4,757,501.80

Ricoh USA, Inc.

Ricoh B&W copier lease, PO # 4500712936

August 2013 to August 2017 at $202.62/month

Ricoh Color MFD lease, PO # 4500841111

September 2017 to August 2021 at $328.17/month

Total 12-month Ricoh lease expense paid for CY2017: $2,528.40

XEROX Corp.

Xerox color copier lease, PO # 4500734496

October 2013 to September 2017 at $398.39/month

Xerox color MFD lease, PO # 4600015253

October 2017 to September 2021 at $319.41/month

Total 12-month Xerox lease expense paid for CY2017: $4,930.13

DELL Marketing LP, PO # 4300540871

SAS Visual Analytics software maintenance

Valid from March 31, 2017 – March 31, 2018

Amount expended in 2017: $11,880.00

Contracts under which the Authority Received

Revenue in 2017 as a Contractor:

Agreements 1 (Completed) & 2 (Ongoing) – Health Literacy Projects

HCIF 2 Total Receipts in 2017: $38,930.23

HAP/CMS subcontract agreement–

Hospital Innovation Improvement Networks (HIIN)

Total Receipts in 2017: $599,266.46

Patient Safety Authority Balance Sheet

Note: This balance sheet reflects the status of the Trust as of December 31, 2017. Source: Office of Comptroller Operations, Commonwealth Bureau of Accounting and Financial Management. CY17 methodology includes an accrual of Board approved FY17-18 Assessment Revenue.

Board of Directors & Public Meetings

Members of the board of directors are appointed by the governor and the general assembly according to certain occupational or residency requirements. As of December 31, 2017, members included:

Physician Appointed by the Governor

Rachel Levine, MD, Physician General (Chair)

Residence: Middletown (Dauphin County)

Appointee of the Speaker of the House

Stanton N. Smullens, MD (Vice Chair)

Residence: Philadelphia (Philadelphia County)

Healthcare Worker Appointed by the Governor

John Bulger, DO, MBA (Secretary/Treasurer)

Residence: Danville (Montour County)

Healthcare Worker Appointed by the Governor

Radheshyam Agrawal, MD

Residence: Pittsburgh (Allegheny County)

Healthcare Worker Appointed by the Governor

Jan Boswinkel, MD

Residence: Havertown (Delaware County)

Appointee the President of Pro Tempore of the Senate

Daniel Glunk, MD, MHCDS

Residence: Williamsport (Lycoming County)

Pharmacist Appointee of the Governor

Arleen Kessler, PharmD, MBA, RPh

Residence: Williamsport (Lycoming County)

Non-healthcare worker appointed by the governor

Mary Ellen Mannix, MRPE

Residence: Wayne (Delaware County)

Appointee of the minority leader of the Senate

Veronica Richards, Esq.

Residence: Warrendale (Allegheny County)

Nurse appointee of the governor

Linda Waddell, RN, MSN, CJCP, CPPS

Residence: New Kensington (Westmoreland County)

Appointee of the Minority Leader of House

Eric Weitz, Esq.

Residence: Lower Merion Twp. (Montgomery County)

The MCARE Act requires the board of directors to meet at least quarterly. During 2017, the board met frequently to assess and develop future patient safety educational and advocacy activities, including developing standards for more consistent reporting. Representatives of healthcare, consumer, and stakeholder groups, including the general assembly, have attended or participated in public meetings.

Dates for all public board meetings in 2017:

January 23, 2017
March 16, 2017
April 20, 2017
June 13, 2017
September 12, 2017
October 17, 2017
December 12, 2017

2017 Patient Safety Authority Annual Report

Executive Summary

2017 Highlights

Strategic Plan 2017 - 2020

Mission

Overview

Improving Diagnosis

Patient Focus

Long-term Care (LTC)

Event Reporting

Educational Outreach

EducationAL Outreach by the Numbers

Improving Safety and Reducing Harm across the Care Continuum

Education Spotlight: Drexel University Law Students

Patient Safety Liaisons

​In the Spotlight Wrong-site Surgery Consultation

I AM Patient Safety

Celebrating Pennsylvania’s Commitment to Patient Safety

2018 Winners

Improving Diagnosis

Good Catch

Focus on the Patient

Innovation

Long-term Care

Ambulatory Surgery

Individual Impact

Video

Best Use of Authority Resources

Improving DIagnosis

Executive Director’s Choice

Improving Diagnosis

Good Catch

Focus on the Patient

Innovation

Long-Term Care

Ambulatory Surgery

Individual Impact

Video

Best Use of Authority Resources

Improving Diagnosis

Patient Safety Advisory

Peer-Reviewed Journal Dedicated to Safety

5,000 Ways the Advisory Has Made Healthcare Safer

Infection Preventionists

Providing Facilities the Resources Necessary to Combat Healthcare-Associated Infections

2017 Infection Preventionist Highlights

Healthcare-associated infections

Pennsylvania LTC Facilities

​Analysis

Urinary Tract Infection (UTI)

Skin and Soft Tissue Infection

Central Line-Associated Blood Stream Infections (CLABSI)

Respiratory Tract Infection

Gastrointestinal Infection

Patient Safety Authority impact

Pennsylvania. United States.

Collaboratives - Antibiotic Stewardship, Anesthesiology, & HIIN

Antibiotic Stewardship

Wrong-site Anesthesia Nerve Blocks

Hospital Improvement Innovation Network (HIIN)

ADVERSE DRUG EVENTS

Falls

CULTURE OF SAFETY

DIAGNOSTIC ERROR

MEDICATION SAFETY-Preventing Error in Outpatient Pharmacies​

Analysis & Prevention Strategies

Standardization - Pressure Injury Reporting

Acute Care data

Pennsylvania Patient Safety Reporting System (PA-PSRS)

Interpreting PA-PSRS Data

Reports by Event Type

Control Charts – How Do You Show Change Over Time?

Reports by Facility Type

Reports by Level of Patient Harm

Patient Demographics: Age and Gender

Event Type and Gender

Age Cohorts - Neonatal Patients

Age Cohorts - Patients 65 or Older

Age Cohorts - Children and Adolescents

Reports by Location/ Department (Hospitals)

In the Spotlight Wrong-site Surgery Consultation

Analysis

MEDICATION SAFETY-Preventing Error in Outpatient Pharmacies