2024 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

If you’ve been following the Patient Safety Authority (PSA) for a while, you probably recognize the above quote from some of our communications. But it isn’t simply a catchphrase or a call to action. It’s also an acknowledgment and a reminder that everything we do is possible thanks to the people and facilities who work with us toward a common goal: safe healthcare for everyone.

PSA was created to partner with facilities to prevent the recurrence of harm, but in order to meet our mandate, we rely on facilities to fulfill theirs. Reporting errors into the Pennsylvania Patient Safety Reporting System (PA-PSRS) is one important way that facilities help us help them.

It can be difficult to talk about what went wrong, but it’s the first step toward figuring out how to stop an event from happening again—which is where we come in. You also may recognize this popular catchphrase: “The more you know.” PSA can only try to identify solutions if we know about the problems that need them in the first place.

Last year, PA-PSRS recorded 315,418 serious events and incidents from acute care facilities in the commonwealth. From another perspective, those reports represent 315,418 opportunities to understand what happened and prevent it from happening ever again—not just in Pennsylvania, but anywhere.

Data from those reports and another 5 million reports submitted to PA-PSRS over the last two decades are collected, studied, and analyzed to detect patterns or trends. We use these analyses to make recommendations; publish our findings in alerts, newsletters, and our journal; and develop strategies and education to raise awareness.

We collaborate more directly with facilities to produce guidance and training, write articles, and create videos about best practices to help keep people safe. We share stories of harm events and resulting improvements to inspire change at other facilities. And each year, we celebrate individuals and teams whose own extraordinary efforts give them the right to proudly say, “I am patient safety.”

As you read about PSA’s accomplishments in the following pages, keep in mind the essential contributions that facilities and healthcare workers and, of course, patients make every day to advance patient safety. PSA can’t do it alone. And so, once more with feeling:

Act 30 of 2006 extended the reporting requirements in the Medical Care Avail- ability and Reduction of Error (MCARE) Act to abortion facilities that perform more than 100 procedures per year. At the end of 2024, 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 un- derlying disease or condition of the patient.”

PSA considers this term to be broader than “medical error,” because some ad- verse events may result from clinical care without necessarily involving an er- ror. 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 per- formed.” At the end of 2024, there were 329 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 2024, Pennsylvania had five qualifying birthing centers.

​

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, dis- abled, 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 2024, Pennsylvania had 214 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 medi- cal facility which could have injured the patient but did not either cause an un- anticipated 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 health- care facility, the availability of clinical services, or criminal activity. The legal definition from the MCARE Act: “an undesirable or unintended event, oc- currence, 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 com- pleted 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: “Ev- ery 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 675 qualifying nursing homes at the end of 2024.

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. Re- ports 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.​

In 2002, Pennsylvania made history by passing and enacting the nation’s most robust patient safety legislation—three years ahead of the federal government. Chapter 3 of the Medical Care Availability and Reduction of Error (MCARE) Act established the Patient Safety Authority (PSA) to improve patient safety across the commonwealth.

Fast-forward 23 years and PSA remains at the forefront, setting the gold standard for state agencies nationwide. Our success stems from our relentless pursuit of excellence, guided by our mission and vision.

In September 2024, PSA’s board greenlit the visionary strategic plan, Reimagine Patient Safety 2029, after an intensive consideration process, stakeholder input, and an in-person workshop to pinpoint the most pressing patient safety challenges and the most effective ways PSA could tackle them.

Reimagine Patient Safety 2029 charts the course for our priorities, decision-making, initiatives, and resource allocation through June 2029, ensuring Pennsylvania remains a beacon of safe healthcare for all patients. The plan is built on three main pillars:

This report highlights how PSA is already making strides toward these goals, such as pioneering artificial intelligence techniques to enhance patient safety data analysis, convening a statewide patient safety advisory panel to help prioritize issues and implement solutions, and deepening our commitment to organizational culture.

PSA identified that the number of serious event reports related to neonatal complications increased by 92% between 2018 and 2022.

To better understand the nature of these events, PSA analyzed all serious event reports identifying neonatal injuries or death related to labor and delivery that occurred in calendar year 2022. PSA also sent a set of questions to facilities related to each of the relevant reports to obtain additional information regarding the events.

 

Fernanda Basso Alcoforado, Main Line Health
While doing her 15-minute safety rounds, mental health technician Fernanda Basso Alcoforado observed a patient on the Inpatient Psychiatric Unit for depression and suicidal ideation who appeared superficial and preoccupied. The patient denied any need for help, but on the next set of rounding, Alcoforado broke from her routine and returned early to the patient’s room. The patient was in the bathroom, denied any issues, and said they would be out soon. Out of continued concern for the patient, Alcoforado entered the bathroom—to find the patient with a shirt tied around their neck. Alcoforado hit their alarm button and untied the shirt. She then stayed with the patient and took them to the nurse’s station for further assistance.

Ambulatory Care

UPMC St. Margaret Harmar Outpatient Center, UPMC St. Margaret
The staff at UPMC St. Margaret Harmar Outpatient Center have demonstrated a commitment to continuous improvement, collaboration, and innovation in patient safety—for example, implementing a dedicated cellphone for communicating with patients, as well as new procedures for pre- and postoperative calls. With an additional focus on pain reassessment management and pediatric orthopedic care, their efforts have enhanced patient outcomes and satisfaction.
Runners-Up

• Jazmin Mendoza — Pennsylvania Hospital – Farm Journal Building
• Julie Triplett AHN — Bethel Park Surgery Center
  

Commitment to Safety

Melissa Lattanzio, Deidre McAllister, Lester Green, Joe Cooney, Tarah McCloskey, Maria Harb, Nina Renzi, and Sonya Wood Johnson, Penn Medicine Rehabilitation
When Penn Medicine Rehabilitation noted an increase in patient elopements (patients leaving the hospital outside of approved activities), this team developed an action plan to reduce the number of events. Noting that many elopements occurred between 6 and 9 p.m., often to purchase food or snacks, they implemented several interventions, including providing vending machines for patients—successfully reducing the number of elopements.
Runners-Up
• Jennifer Higgins — WellSpan Good Samaritan Hospital
• Perioperative Services Leadership and Education Team — Pennsylvania Hospital

Healthcare Disparity

Sarah Prylinski, UPMC Hamot
Sarah Prylinski at UPMC Hamot led the development and implementation of a groundbreaking street medicine program that helps meet the needs of individuals experiencing homelessness. Whether in shelters or on the streets, she provides education on medication, administers vaccines, cares for wounds and infections, schedules and attends medical appointments with patients, and more—improving their access to healthcare and fostering trust and dignity in this vulnerable population.
Runners-Up

• Michele Ferguson Davis, Guljinder Chera, Salman Qureshi, Bunmi Olarewaju, and Patricia Nichols — Jefferson Torresdale Hospital
• Community Health Needs Assessment Committee: Terri Pellegrino, LaQuicha Anderson, Valerie Bicker, Diane Corr, Donna Tassos, Lia Gallagher, Kristen Guinther, Daniel Hedayati, Michele Hilty, Carole Hoy, Michelle Ikoma, Bill Jordan, Kevin Macdonald, Megan McGrady, Jennifer McMahon, James Mercuri, Lacey Murray, Erin O'Connor, Michele Orsini, Alex Pantoja, Sanketh Proddutur, Courtney Riedel, Bethany Rose, Justin Rose, Ryan Witt, Chelsey Wojcik, Linda Yelen, and Faith Colen — UPMC St. Margaret 

Improving Diagnosis

Penn Medicine Enterprise High Sensitivity Troponin Implementation Team,
Penn Medicine
The Penn Medicine Enterprise High Sensitivity Troponin Implementation Team developed chest pain algorithms to reduce the risks associated with the use of high-sensitivity cardiac troponin assays (hs-cTn), such as diagnostic errors, inappropriate admissions, and rise in cardiology consultations and unnecessary imaging. Implemented across five participating hospitals, the initiative generated over $3.9 million in savings within 10 months by reducing length of stay, enhancing patient throughput, and increasing ED capacity.
Runners-Up

• Jefferson Health and Bensalem Rescue Squad Mobile Stroke Unit — Jefferson Torresdale Hospital
• Saundra Jones — UPMC St. Margaret

Individual Impact

Andrea Colfer, Children’s Hospital of Philadelphia
Andrea Colfer has been a driving force for innovation at Children’s Hospital of Philadelphia, from proposing an enterprisewide refresh of major event analysis to creating a book club to spark conversation around patient safety. In her role and beyond, she always advocates for including the voice of the patient or family as the team considers any harm and gives every event review careful thought and attention.
Runners-Up
Gustaaf de Ridder and Physician Clinical Pathology Laboratory Medicine PhDs — Geisinger Medical Center
Elizabeth King — Penn State Health Milton S. Hershey Medical Center

Medication Safety

Christine Zdaniewski, UPMC Hamot
Christine Zdaniewski, a clinical pharmacy specialist at UPMC Hamot, reported 16 medication-related events in 2024, with 10 being good catches or pharmacy interventions that had significant patient impact. In her work she demonstrates commitment to collaboration, communication, and education; for example, after reporting a medication event involving low-dose ketamine administration for pain, she partnered with the ordering physician and his team to develop educational materials for pharmacy and nursing.
Runners-Up

• Maryann Scholl — UPMC Hamot
• Infusion Center Pharmacy Nursing Workgroup — Pennsylvania Hospital 

Patient Communication

Lisa Kolodziejski, UPMC St. Margaret
Lisa Kolodziejski, orthopedic nurse navigator at UPMC St. Margaret, expanded not only access to presurgical classes for total joint replacement patients by offering them online and in evenings, but also the content of the classes. She incorporated a dietician, physical therapist, and occupational therapist in lessons to instruct patients on best practices before and after surgery for better healing and recovery. She also visits overnight patients after surgery to encourage them towards discharge and reinforce education, which continues through phone calls following discharge. Through these advances and additional efforts with the geriatric fracture program and community outreach, she has been helping reduce harm and improve outcomes.
Runners-Up

• Kirkland Village Healthcare Center Clinical Team — Kirkland Village
• Melissa Smock — UPMC Hamot
  

Safety Story

Women and Children Teams and Pulmonary Services Team, WellSpan York Hospital
A scheduled medical gas shutdown at the hospital experienced an unexpected issue, affecting a critical care unit. The clinical coordinator and charge nurse
acted swiftly, coordinating with other staff and leadership to ensure patient safety. Teams provided essential resources and worked tirelessly to keep all ventilators functioning. Thanks to the staff’s resiliency and teamwork, all patients received appropriate care and remained on the unit until the medical gas was restored. The hospital is now identifying opportunities for improvement, including evaluating the unit’s evacuation plan and enhancing communication processes.
Runners-Up

• Robert Bayer and John Paoletti — Jefferson Torresdale
• Maura Kessler — Lehigh Valley Hospital–Pocono

Transparency and Safety in Healthcare

The Nurses at the Crozer Endoscopy Center at Brinton Lake, Crozer Health The nurses at the Crozer Endoscopy Center at Brinton Lake implemented an action plan to complete risk event reports for multiple events that were
not captured previously due to lack of knowledge, or other reasons, as well as to encourage event reporting. After providing education and posting a list of possible events at every nurse's station, the number of event types being reported increased, as did the numbers of event reports and nurses reporting. The nurses now feel safe in being transparent in event reporting.
Runners-Up

• Rebecca Geddes and the PAH Patient Safety Team — Pennsylvania Hospital
• Lisa Esolen, Kelly Goff, Matthew Jesso, and the System Quality Department — The Guthrie Clinic

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, 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 (PSTF). Funds are received primarily from assessment surcharges collected by the Pennsylvania Department of Health (DOH) from licensed MCARE healthcare facilities.

Pennsylvania hospitals, ambulatory surgical facilities, abortion facilities, birthing centers, and nursing homes bear the financial responsibility for funding MCARE’s 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 healthcare facilities paying for the Pennsylvania Patient Safety Reporting System (PA-PSRS) receive 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 MCARE chapters 3 and 4. Consistent with this mandate, PSA may at times contract to receive funds from other healthcare-related entities to reduce medical errors and promote patient safety in the commonwealth. In 2024, PSA received no contract funding.

A variety of analytical tools is integrated within the design of PA-PSRS providing immediate and direct feedback to each facility on adverse event and near-miss reporting. Additionally, in 2024, 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 2024, PSA added new functionality and design upgrades to the PA-PSRS Application Modernization (AMOD) project that was initiated in 2019 as a complete redesign of the PA-PSRS application.

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.