2023 Patient Safety Authority Annual Report

Nirmal Joshi, MD (Chair), Physician Appointed by the Governor

Daniel Glunk, MD, MHCDS (Vice Chair), Appointed by the President Pro Tempore of the Senate

Veronica Richards, Esq. (Secretary/Treasurer), Appointed by the Minority Leader of the Senate

Mayank Amin, PharmD, MBA, RPh, Pharmacist Appointed by the Governor

Daniel Feinberg, MD, Healthcare Worker Appointed by the Governor

Samuel Hammerman, MD, Healthcare Worker Appointed by the Governor

Lynn Kornblau, Esq., Nonhealthcare Worker Appointed by the Governor

Kathleen Law, DNP, MS, RN, Healthcare Worker Appointed by the Governor, through March 2024

Heidi McMullan, MSN, RN-BC, Nurse Appointed by the Governor

Amelia Paré, MD, Appointed by the Speaker of the House of Representatives

Linda Waddell, MSN, RN, Nurse Appointed by the Governor, through May 2024

Eric Weitz, Esq., Appointed by the Minority Leader of House

William J. Wenner, MD, JD, Physician Appointed by the Governor

Leadership

Regina M. Hoffman, MBA, RN, Executive Director
Howard Newstadt, JD, MBA, Sr. Dir., Finance & Business Ops/CIO/CISO
Caitlyn Allen, MPH, Director, External Affairs
Michelle Bell, BSN, RN, Director, Outreach & Education 

Rebecca Jones, MBA, RN, Director, Data Science & Research 

Jesse Munn, MBA, Director, Transformation & Strategic Initiatives 

Addie A. Abelson, Esq., Legal Counsel
Amber Sizemore, Esq., Legal Counsel

Staff
JoAnn Adkins, BSN, RN, Infection Prevention Advisor
TJ Arnold, Business Operations Manager
Amanda Bennett, MPH, MLS, Infection Prevention Advisor 
Christine Bingman, DNP, RN, Infection Prevention Advisor 
Denise Cutting, MSN, MSH, RN, Infection Prevention Advisor 
Kathleen Dohey MSN, RN, Patient Safety Advisor
Shirley Dominick, MSN, RN, Patient Safety Advisor
Kelly R. Gipson, BSN, RN, Project Manager
Shawn Kepner, MS, Data Analyst
Richard Kundravi, BS, Patient Safety Advisor
Christopher Mamrol, BSN, RN, Patient Safety Advisor 
Karen McKinnon-Lipsett, Office Coord./Sr. Admin. Specialist 
Shelly M. Mixell, Administrative Specialist
Melanie A. Motts, MEd, RN, Patient Safety Advisor
Eugene Myers, BA, Associate Editor
Jessica Oaks, MIT, Program Manager
Jacqualine Peck, BS, Communications Specialist
Molly Quesenberry, BSN, RN, Patient Safety Advisor 
Catherine M. Reynolds, DL, MJ, RN, Patient Safety Advisor 
Sunny Ro, PharmD, Research Scientist
Christine Sanchez, MPH, Research Scientist 
Megan Shetterly, MS, RN, Patient Safety Advisor 
Krista Soverino, BFA, Communications Specialist
Heather A. Stone, BSW, People Partner & Strategic Assistant
Matthew Taylor, PhD, Research Scientist
Alex Ulsh, BCS, Systems Administrator/Deputy CISO
Robert Yonash, RN, Patient Safety Advisor

Contractors

Katie Adams, MS
Carol Beckman, MSI, 
MS Lucy Bocknek, MS, OTR/L 
Christian Boxley, BS 
Phyllis Bray
Deanna Busog, BS
Heather David, MSN, CRNP 
Shannon Davila, MSN, RN 
Ella Franklin, MSN, RN
Kelly C. Graham, BSN, RN 
Joanna Grimes, BSN, RN 
Matthew Grissinger, RPh 
Jessica Handley, MA 
Donna Jackson
Sadaf Kazi, PhD
Shawn Kincaid, BA, BSME, EIT 
Seth Krevat, MD
Arianna Milicia, BS
Srutheka Polsani 
Zoe Pruitt, MA 
Raj Ratwani, PhD
Patricia Spaar, MSN, RN 
Carly Sterner
Jeraldine S. Stoltzfus, MBA-HA, RN 
Anna L. Thomas, MSN, RN 
Madelyn Woodward

Public Board Meetings in 2024

January 25, 2024

April 25, 2024

June 20, 2024

September 19, 2024

December 12, 2024

Summary minutes of public board meetings are available at patientsafety.pa.gov.

Annual Report Production Staff
Daniel Glunk 
Eric Weitz 
Regina Hoffman 
Caitlyn Allen 
Eugene Myers 
Krista Soverino 
Heather Stone

When you see the letters PSA, “public service announcement” is likely the first thing that comes to mind; however, in Pennsylvania, PSA commonly refers to something else: the Patient Safety Authority.

While public service announcements are some of what we do, we don’t stop at raising awareness of safety and health concerns. Rather, we actively partner with healthcare facilities in identifying potential risks, developing strategies to prevent harm, and collaborating with those who can best use them to protect patients and staff.

How do we accomplish this? The core component of our work is PA-PSRS, the Pennsylvania Patient Safety Reporting System—the nation’s largest event reporting database and one of the largest of its kind worldwide, with more than 5 million reports. Acute care facilities are required to report all incidents of harm or potential for harm, in accordance with the Pennsylvania Medical Care Availability and Reduction of Error Act. Commonly called the MCARE Act or Act 13 of 2002, this is the same legislation that created the PSA as an independent state agency, under a board of directors appointed by the governor and state legislature. Similarly, long-term care facilities report infections into PA-PSRS, as outlined by Act 52 of 2007.

Do you know that Pennsylvania is the only state in the country that requires healthcare facilities to report serious events and incidents? As the saying goes, “knowledge is power,” and this patient safety information is among our most vital tools for improving the quality of healthcare. Unlike health regulatory agencies, PSA collects and analyzes these reports solely to better advise facilities through publication, education, collaboration, and recommendations.

Every report in PA-PSRS helps prevent an event from happening again, allowing PSA to identify trends unapparent to a single facility or flag a single event that has a high likelihood of recurrence. In 2022 alone, 256,679 serious events and incidents were reported to PA-PSRS, which our analysts studied and analyzed to focus improvements. Their data were published in the PSA’s award-winning journal, Patient Safety, reaching more than 75,000 readers throughout all 50 U.S. states and 174 countries.

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 2023, Pennsylvania had 18 qualifying abortion facilities.

This term is commonly used when discussing patient safety, but it is not defined in the MCARE Act. The Institute of Medicine Committee on Data Standards for Patient Safety defines an adverse event as “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.” PSA considers this term to be broader than “medical error,” because some adverse events may result from clinical care without necessarily involving an error. And not all adverse events are preventable. Although the Pennsylvania Patient Safety Reporting System (PA-PSRS) includes reports of events that resulted from errors, PSA’s focus is on the broader scope of actual and potential adverse events, not only those that result from errors.

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 multispecialty 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 2023, there were 328 qualifying ASFs in Pennsylvania.

The HCFA defines a birthing center as “a facility not part of a hospital which provides maternity care to childbearing families not requiring hospitalization. A birth[ing] center provides a homelike atmosphere for maternity care, including prenatal labor, delivery, and postpartum care related to medically uncomplicated pregnancies.” At the end of 2023, Pennsylvania had five 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 2023, Pennsylvania had 218 qualifying hospitals.

A “potential adverse event”: An event which either did not reach the patient (“near miss”) or did reach the patient but 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 healthcare services to the patient. The term does not include a serious event.”

A potential patient safety event associated with the physical plant of a healthcare 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.

A “preventable adverse event”: 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 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).” Definitions 4 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.”

Act 52 of 2007 revised the MCARE Act to require nursing homes to report healthcare-associated infections (HAIs) to PSA. Specifically, the act states that “the occurrence of a healthcare-associated infection in a healthcare 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 682 qualifying nursing homes at the end of 2023.

The Centers for Medicare & 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 PSA 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.

An event, occurence, or condition that could have resulted or did result in harm to a patient and can be but is not necessarily the result of a defective system or process design, a system breakdown, equipment failure, or human error. It can also include adverse events, no-harm events, near misses, and hazardous conditions.

The patient safety advisor is a unique resource to Pennsylvania MCARE facilities. Serving as the face of PSA, the advisors provide education and consultation to MCARE facilities and ensures that facilities are aware of the resources available to them through PSA, such as educational toolkits, presentations, and webinars. The program has eight acute care and four infection prevention advisors located regionally throughout Pennsylvania.

The MCARE Act requires each medical facility to designate someone 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 PSA.

The research scientist is a member of PSA with education and experience in medicine, nursing, pharmacy, product engineering, statistical analysis, and/ or risk management. Research scientists review events submitted through PA-PSRS and compose articles included in PSA’s peer-reviewed journal, Patient Safety.

The legal definition from the MCARE Act: “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 healthcare services to the patient. The term does not include an incident.”

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. PSA, DOH, and healthcare facility staffs 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 PSA and DOH.

The Pennsylvania Patient Safety Reporting System (PA-PSRS) is not only a direct way for healthcare facilities to communicate with us about errors that occur, but also a powerful tool to prevent them from recurring— at that facility, at other Pennsylvania facilities, and even beyond the commonwealth.

The more than 5 million reports in PA-PSRS aren’t just data: Each report represents people and lives affected by a serious event or incident. Each tells a story about what happened and why it happened. And each is an opportunity to do better next time and every time thereafter.

Last year we worked to remind our partners in facilities of their essential role in reporting events, how to classify and report them, and how this helps make patients safer. We notified healthcare workers of safety issues and emerging trends revealed by the information they provided, and in a new initiative, we began highlighting event reports that triggered improvements across hospitals, health systems, and the nation.

In a searchable microsite, we published dozens of stories about people who looked at “what happened” and focused on “what happens next,” demonstrating how they were inspired to make changes that improved patient care and safety. In the coming year we will continue to promote timely and accurate event reporting and share more stories that demonstrate its transformative, lasting impact.

Nikki Verkleeren and the Pharmacy Team at Forbes Hospital, Allegheny Health Network
When a patient received high amounts of a narcotic due to their patient-controlled analgesia (PCA) pump being reprogrammed for an ordered increase, Nikki Verkleeren, PharmD, and the Pharmacy team at AHN-Forbes became passionate about addressing this safety risk. Their efforts turned into a network-level project with multiple facets that ultimately led to not only a new and improved and standardized PCA order set, but also a standardized drug library, standardized epidural orders, and a networkwide equipment upgrade. The work and leadership required to carry this project through while Verkleeren conducted her normal day-to-day responsibilities was immense, but patients are safer across the entire system for it.

The staff of the Reading Hospital SurgiCenter at Spring Ridge
Recognizing that the fast-paced environment of an ambulatory surgery center lends itself to creating opportunity for error, the staff at Reading Hospital SurgiCenter at Spring Ridge made it their mission to prevent future wrong-patient, -implant, -side, and -site surgery errors. In particular, they focused on improving physician engagement during the time-out in the operating room, when all work except ventilation is supposed to pause during confirmation of patient information. In order to ensure the full attention of surgeons, staff was reeducated on the importance of the time-out and empowered to speak up if someone is distracted or they have a concern. The back table also was removed from the surgical field, to provide better focus during the time-out. These efforts improved the surgeon engagement rate from 83% in calendar year 2021 to 92% in the first three quarters of CY 2023.
Runners-Up

• Einstein Endoscopy Center Blue Bell — Jefferson Health
• Randi Shupp, PA-C — Lehigh Valley Health Network–Tilghman

Jessica Schumann, DO, Parmjyot Singh, DO, Neophytos Zambas, DO, Benjamin Slovis, MD, MA, and Jaclyn King, MS, RT, at Jefferson Torresdale Hospital
Emergency department (ED) clinicians routinely use clinical calculators and scores to aid in medical decision-making, and these evidence-based tools are built into Jefferson’s electronic health record (EHR). An ED physician, residents, and EHR experts at Jefferson Torresdale Hospital conducted a laborious review of the existent tools and updated clinical scores and assessments. These updates are more user-friendly and help clinicians create patient care plans more quickly and efficiently across 11 Jefferson EDs.
Runners-Up

• The Center for Diagnostic Leadership Team: Dan Hyman, MD, Kathy Shaw, MD, Eileen Ware, MSN, RN, Meghan Galligan, MD, Cara Jefferies, MSN, RN, Irit Rasooly, MD, Jill Krause, MD, Morgan Cogdon, MD, Rich Scarfone, MD — Children’s Hospital of Philadelphia
• Emergency Department, Emergency Department Registration, andCardiology Department EKG Techs — Saint Vincent

Individual Impact

At Jefferson Torresdale Hospital, Dawn Goodwin, patient care technician, and Shamaine McGlone, patient safety associate, worked closely with a patient whose behavior was not initially favorable to receiving safe care in the hospital to being receptive to inpatient care and treatment. They were able to do this by building a good rapport with the patient, and this connection comforted and redirected the patient. Their patience and caring greatly improved the situation for the patient and their colleagues.
Runners-Up

• Chelsea Johns, RDN — Hamilton Health Center
• Ruchi O’Reilly, MSN, RN, — Thomas Jefferson University Hospitals

Patients at Risk (PAR) Committee Members, Providence Point: Rosie Minniti, Senida Nuhanovic, Angela Wright, Jodie Roese, Suzanne Sawicky, Sarah Leuch, Jillian Wagner, DJ Turner, Brianna Houck, RN, and Dina Alexander
Upon the closure of a facility, many staff members from all departments transferred to Providence Point. The Patients at Risk (PAR) meeting was formed as a way for the resulting interdisciplinary team to engage in meaningful discussions and formalize residents’ individual plans of care, considering their emotional, social, and spiritual needs. This team, being relatively new to one another and to the facility, strived for the best outcomes for the residents and worked together to identify resident risk and swift intervention to promote positive outcomes. They met weekly and proactively identified residents at risk using analytical data derived from clinical software, such as review of residents triggering on the quality measure reports, infections, falls, grievances, weights, therapy concerns, and medical record documentation. The kick-off meeting was held in June 2023 and the team determined to focus on falls with major injuries, associated in-house acquired infections, and antipsychotic medications. As a result of their commitment to patient safety and continued dedication to provide the best outcomes for residents, and their ongoing efforts in identifying, planning, educating, and coaching, by Quarter 3 the facility had achieved zero falls, zero urinary tract infections, and no new antipsychotics administered.
Runners-Up

• Georgina Philbin, RN — Willow Brooke Court Skilled Care Center at Brittany Pointe Estates
  
• Juniper Bucks Skilled Nursing Rehab: Theresa Bush, RN, Stephanie Nemeth, RN, Nicole Sokolow-ska, Emily Kielar, Princy Vaidyan, RN, Heidi Burk, Dr. Neal Mermelstein — Juniper Village at Bucks County Rehabilitation and Skilled Care

Dr. Mohamed Shitia, Dr. Kevin Colleran, Dr. Arron Wey, and Dr. Shazad Shaikh at Geisinger Orthopaedics and Sports Medicine Scranton
A grateful family credits Drs. Mohamed Shitia, Kevin Colleran, Arron Wey, and Shazad Shaikh at Geisinger Orthopaedics and Sports Medicine Scranton with getting their soccer-playing daughter back on her feet and onto the field after she sustained multiple, serious injuries over five years. From the 8th grade through her senior year of high school, she sustained fractures, an anterior cruciate ligament (ACL) tear, and finally tears to the tendon and ligament in the ankle and an issue with the medial talar dome. Each time, these orthopedic physicians provided compassionate care and expertise that enabled her to heal and continue to play— and help her team win conference and district titles for three straight years.
Runners-Up

• Medical Oncology Department: Jill Ranochak, RN, Maggie Spaeder-Hodges, RN, Danielle Klingerman, RN, and Valerie Dietz — Jefferson Einstein Montgomery Hospital
• Lindsay Liggett — WellSpan Franklin ENT

The Emeritus Nurse Program at Penn State Health Milton S. Hershey Medical Center
The Emeritus Nurse Program at Penn State Health Milton S. Hershey Medical Center has arguably prevented harm in hundreds of vulnerable patients. Emeritus nurses (E-RNs) are seasoned and often retired registered nurses who work on a per diem basis, primarily supporting the bedside nursing staff in reviewing and delivering discharge instructions directly to patients. Originally created and launched as an innovative staffing strategy, the E-RNs have emerged as safety champions. They have documented and helped resolve over 215 near miss events related to discharge instruction errors. These great catches are frequently found in conversation with the patient and through investigation into the electronic health record, including home medication reconciliation, inpatient orders, and physician progress notes. Because their time is dedicated to this work, E-RNs have been able to stop and resolve many discharge medication errors related to duplication, omission, and appropriate dosing. In a time when technology can be slow, incomplete, complicated, and expensive, E-RNs have been able to intervene as a final safety barrier in the continuum of care. Discharge can be a confusing time for patients and their families, but E-RNs’ knowledge and diligence have been a true gift to them and the organization over the last year.
Runners-Up

• Lyndsay Horwedel, BSN, RN, Olivia Johnson, PharmD, Kelly Romano, and Carlos Ayala — Jefferson Einstein Montgomery
  
• Emergency Response Team — WVU Medicine–Uniontown Hospital
  

Crystal Ratkovsky, CCRN, at UPMC Hamot
Crystal Ratkovsky, CCRN, is a dedicated nurse at UPMC Hamot with over 15 years of experience who has a focused passion around sepsis. She led the initiative to introduce a sepsis alert for patients meeting the criteria of sepsis/systemic inflammatory response syndrome (SIRS) and developed a sepsis screening tool and checklist. Recognizing the need for staff on all units to be well versed on the topic of sepsis, early recognition, and proper and timely treatment, she also developed a sepsis committee to focus on active staff participation as sepsis coaches and champions who provide sepsis education to clinical and medical staff. Her sepsis initiatives have had a significant impact on reducing further harm and improving patient care and outcomes, and it is sustainable, reliable, and scalable. The sepsis alert alone has helped staff become more knowledgeable in identifying the signs and symptoms of sepsis, and they have become more confident in collaborating with providers with their assessment. The team of sepsis coaches and champions she developed has educated their peers on sepsis recognition and improved the treatment of sepsis.
Runners-Up

• Sepsis Improvement Team — Regional Hospital of Scranton,
• Commonwealth Health • Emergency Department — Grove City Hospital

The Department of Surgery, Jefferson Abington Health
The Department of Surgery at Jefferson Abington Hospital identified an opportunity to revise its time-out policy when there is a change in surgical modality, such as minimally invasive surgery (laparoscopic or robotic) to open surgery. When there is a pivot from one procedure to another, a mandatory second time-out will occur. This is an innovative solution to a low-volume, high-risk situation and puts patient safety first.
Runners-Up

• Joanne Braswell — Forbes Hospital, Allegheny Health Network
• Abbe Seidel, RN — Lehigh Valley Hospital–Cedar Crest

OB/Newborn Patient Safety and Quality Committee, UPMC Hamot
A subgaleal hemorrhage is a rare but potentially lethal event in newborns: a life-threatening emergency caused by bleeding that accumulates between the skull and the scalp, especially with vacuum-assisted births. After an undiagnosed subgaleal hemorragh led to a newborn’s death, the OB/Newborn Patient Safety and Quality committee at UPMC Hamot reflected on their errors, identified process improvement strategies for implementation, and shared the story. This team reviewed the event extensively and identified opportunities for education, assessment skills, and the need for a tool that would enable the staff to identify potential brain bleeds in these cases more quickly. The committee developed education and a tool that is now mandatory for all staff in the maternity departments: All newborns delivered with an instrumental assist are to have surveillance observations and examination of the head at 1, 2, 3, 4, 6, 8, and 12 hours of age. If there are any changes in the newborn from the immediate baseline, staff is to reach out for a bedside evaluation by the neonatal intensive care unit (NICU) or pediatric provider and a complete blood count is to be ordered. In addition to implementing these process improvements, the committee shared the story with other newborn facilities for awareness and education to prevent this event from recurring.
Runners-Up

• Magdalena Moyer — Penn State Health St. Joseph - Cancer Center
  
• UPMC West Shore Surgical Services and Executive Leaders — UPMC West Shore

The Medical Care Availability and Reduction of Error (MCARE) Act¹ establishes the Patient Safety Trust Fund as a separate account in the Pennsylvania Treasury. Under the MCARE Act, the Patient Safety Authority (PSA) determines how those funds are used to effectuate the patient safety provisions of the MCARE Act and administers funds in the Patient Safety Trust Fund. Funds come primarily from assessment surcharges collected by the Pennsylvania Department of Health (DOH) from licensed MCARE medical facilities.

Pennsylvania hospitals, ambulatory surgical facilities, abortion facilities, birthing centers, and nursing homes bear the financial responsibility for funding the MCARE mandatory reporting program. Accordingly, PSA 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 the Pennsylvania Patient Safety Reporting System (PA-PSRS) receive in return direct benefits from PA-PSRS and other PSA programs. Pursuant to Section 304(A)(4) of the MCARE Act, as a general rule, PSA is authorized to receive funds from any source consistent with PSA’s purposes under the Act. Consistent with this mandate, PSA at times contracts with and receives funding from other healthcare-related entities to reduce medical errors and promote patient safety in the Commonwealth. In 2023, PSA received no contract funding in addition to MCARE Assessments.

Within the design of PA-PSRS, PSA includes a variety of integral and analytical tools providing immediate, direct feedback to each facility on adverse event and near-miss reports and activities. Additionally in 2023, PSA continued to enhance its public website patientsafety.pa.gov with expanded access to PSA’s educational materials and programs, as well as with enhanced accessibility design. Also in 2023, PSA continued to add both functional and design upgrades to its PA-PSRS Application Modernization (AMOD) project that was initiated in 2019 as a complete redesign of the PA-PSRS application.

During calendar year 2023 (CY2023), PSA spent $6,985,416 (Table 3a). PSA received no contract- or service-related receipts in 2023 and received investment income of $535,930 (Table 3b).

 

NOTES

1. Medical Care Availability and Reduction of Error (MCARE) Act of March 20, 2002, P.L. 154, No 13 40. Available: http://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck. cfm?yr=2002&sessInd=0&act=13.

2. Medical Care Availability and Reduction of Error (MCARE) Act - Reduction and Prevention of Health Care-Associated Infection and Long-Term Care Nursing Facilities Act of July 20, 2007, P.L. 331, No.52, Cl.40. http://www.legis.state.pa.us/cfdocs/legis/li/ uconsCheck.cfm?yr=2007&sessInd=0&act=52.

The MCARE Act requires that PSA 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 PSA last year. However, PSA 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.