Masthead
Board of Directors
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
Heidi McMullan, MSN, RN-BC
Nurse Appointed by the Governor
Amelia Paré, MD
Appointed by the Speaker of the House of Representatives
Indu Poornima, MD, MS
Physician Appointed by the Governor
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
TJ Arnold, BA, Business Operations Manager
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
Staff
JoAnn Adkins, BSN, RN, Infection Prevention Advisor
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
Monica Magee, BSN, RN, Infection Prevention Advisor
Christopher Mamrol, BSN, RN, Patient Safety Advisor
Lana Mason, MPH, RN, Infection Prevention Advisor
Karen McKinnon-Lipsett, Office Coord./Sr. Admin. Specialist
Shelly M. Mixell, Education 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 Myungsun 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
Michele Tracanna, MSN, RN, Patient Safety Advisor
Alex Ulsh, BCS, Certified Systems Administrator/Deputy CISO
Contractors
Carol Beckman, MSI, MS Phyllis Bray
Kim Cahill, MBA, RN Lisa Cahill
Donna Jackson
Shawn Kincaid, BA, BSME, EIT Shannon Kooker, MSN, RN
Savvas Pavlides,PhD Alfredo Penzo-Mendez, PhD Michael Phillips, MA Srutheka Polsani
Carly Sterner
Anna Thomas, MSN, RN Madelyn Woodward
Public Board Meetings in 2025
February 18, 2025
April 29, 2025
June 17, 2025
September 16, 2025
December 9, 2025
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
Introduction
“If you build it, they will come.”
You’re probably familiar with the above quote, adapted from the film Field of Dreams. Our dream, of course, is safe healthcare for everyone, but whether you’re building a baseball field or the future of patient safety, construction doesn’t begin overnight.
First you need a well-considered plan, such as the Medical Care Availability and Reduction of Error (MCARE) Act, which more than 20 years ago made Pennsylvania the only state that mandates reporting of safety events, no matter how serious. That groundbreaking legislation established the Patient Safety Authority (PSA) as the foundation for our mission to “improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information; advising facilities through publication, education, and collaboration; and issuing recommendations for improvement.”
Building also requires the right tools and people to do the job, such as the Pennsylvania Patient Safety Reporting System (PA-PSRS), the largest event reporting database of its kind in the United States, and PSA’s diverse team that includes advisors, infection preventionists, data scientists, communicators, and more—all skilled experts in their own fields.
To evoke another well-known saying: “Rome wasn’t built in a day.” So it is with advancing patient safety. Since PSA was created in 2002, we’ve been building many things in many different areas. First and foremost, we’ve developed strong relationships with hospitals and facilities across the commonwealth, as well as lawmakers, patient safety leaders, organizations, patients and families, and advocates who share our dream. Constructing something that will last requires collaboration and steadfast commitment: everything we do, we do together.
As you’ll read in the following pages, much of what PSA accomplished in 2025 has continued to lay groundwork for exciting, transformative work to come, guided by another blueprint for success: our Reimagine Patient Safety 2029 strategic plan. From new and expanded education initiatives to exploring emerging technologies and services to investing in greater efficiency and effectiveness, we are not only building more but building better.
We’ve seen the impact of these efforts in increased numbers of event reporting; growing readership and submissions for our journal, Patient Safety; broader participation in webinars, training, and in-person learning opportunities; stronger engagement with our stakeholders and communities. As we build, people are joining us, and with their help, further success will come.
Thank you for building something great with us.
DEFINITIONS
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. During 2025, Pennsylvania had 17 qualifying abortion facilities.
ADVERSE EVENT
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.
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 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.” During 2025, there were 327 qualifying ASFs in Pennsylvania.
BIRTHING CENTER
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.” During 2025, 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.” During 2025, Pennsylvania had 215 qualifying hospitals.
INCIDENT
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.”
INFRASTRUCTURE FAILURE
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.
MEDICAL ERROR
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).”
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 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. During 2025, Pennsylvania had 669 qualifying nursing homes.
OTHER EVENT TYPE
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.
PATIENT SAFETY EVENT
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.
PATIENT SAFETY ADVISOR
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.
PATIENT SAFETY OFFICER
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.
RESEARCH SCIENTIST
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.
SERIOUS EVENT
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.”
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.
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.
Executive Summary
As one of the oldest patient safety–centric institutions on the planet, we have come to appreciate the importance of one resource more than anything else: time.
Mismanagement of time is often the reason that many organizations fail;
either they wait too long to evolve and adapt, or they rush into something without fully understanding it first.
Recognizing this common mistake is why our focus for 2025 was to make the best use of our constituents’ time. We created new opportunities for efficiency, such as our patient safety– and infection prevention–focused virtual office hours, which provide a forum for healthcare professionals to meet regularly with PSA experts and their colleagues to get comprehensive answers to pressing issues. We applied for Joint Accreditation, which extends our ability to provide continuing education credits to physicians and pharmacists (in addition to nurses). This ensures busy clinicians won’t have to choose between trainings that they find useful and those that only meet their licensure requirements.
We also focused on methodically laying the groundwork for several first-of-their-kind initiatives, such as the implementation of artificial intelligence to enhance our data analytic capabilities and developing a component patient safety organization (PSO) that will provide Pennsylvania facilities with additional resources to prevent recurrence of events.
We look forward to sharing more about our long-term investments as they unfold and invite you to learn more about everything that PSA did this past year to reduce patient harm.
Outreach & Education
Each year,the Outreach & Education team develops a project (“Keystone”) around a specific focus area, such as reporting, leadership engagement, ligature risk, and improving diagnosis. We wrapped up “Keystone: Keys to Infection Prevention in Ambulatory Surgery” in June 2025, which focused on the unique needs of ambulatory surgical facilities (ASFs) in preventing infections. This project was a joint effort involving everyone on the O&E team; over its 12-month duration, our patient safety advisors and infection prevention advisors conducted 387 in-person Keystone visits. They also covered infection prevention topics, such as infection control risk assessment (ICRA) standards for construction, in the fall 2025 Ambulatory Surgical Facilities Symposia held in several regions in the commonwealth. Related online education included the webinar “Instrument Cleaning, Sterilization, and Storage for Infection Preventionists in ASFs.”
We launched “Keystone: Keys to Engaging Leaders” in July 2025 with the webinar “Charting the Course for Leadership Engagement,” which reviewed the national initiatives that have been developed to advance patient safety, identified current barriers to prioritizing patient safety in healthcare, and outlined the components of the Keystone. During the first six months of this project, patient safety advisors have had 234 one-to-one visits with patient safety officers (PSOs), reviewing the Keystone resources (including a project guide for PSOs and an assessment tool), and advising on facility-specific implementation of strategies to engage leadership in patient safety.
We also introduced a new platform to increase open, consistent communication with our facilities: virtual office hours with PSA advisors. Infection Prevention Office Hours began in May 2025 and are generally held on the second Tuesday of each month. These interactive, 30-minute sessions are designed to provide relevant, practical, and timely information about current topics and emerging issues in infection prevention in long-term care (LTC). They also provide a forum for participants to ask questions, exchange information and experiences, and network with each other. Although these office hours are tailored for infection preventionists, anyone in healthcare or with an interest in infection prevention and patient safety is welcome.
In addition to the monthly office hours, we again held LTC Infection Prevention Symposia in three locations across Pennsylvania. These provided in-person workshops focused on criteria and conditions required to identify infections, environmental rounding components that impact patient safety, how facilities can use data to develop goals and revise their annual infection prevention plans, multidrug-resistant organisms (MDROs) and isolation, and how to become acquainted with construction processes and blueprint drawings.
Strategic Plan
2025 marked transformative efforts by PSA under its Reimagine Patient Safety 2029 strategic plan.
For example, PSA’s Board of Directors approved PSA to pursue forming a component patient safety organization (i.e., an entity listed pursuant to the Patient Safety and Quality Improvement Act of 2005). As PSA’s fourth strategic plan Goal, establishing a component patient safety organization is intended to further enable provider participation and enhance collaborative learning on priority patient safety issues.
Multiyear Strategies to achieve the four Goals are summarized as follows:
- Enhance existing systems and processes to improve quality of data
- Continue developing and exploring artificial intelligence (AI) techniques to enhance analysis of data
- Explore and leverage new or alternate information sources to increase understanding of patient safety problems
- Continue standardization of event reporting
- Explore patient safety surveillance systems
- Convene a statewide patient safety advisory panel
- Strengthen the connection to patients and families
- Accelerate dissemination of risk reduction strategies
- Deepen commitment to organizational culture
- Sustain continuous enhancement of efficiency, quality, and overall organizational performance
- Develop and launch a component patient safety organization, maintain the listing, and grow its reach to continue to elevate patient safety
During the year, PSA completed actions (Tactics) associated with these Strategies, including the following:
- Explore patient safety surveillance systems
- Assembled a statewide patient safety advisory panel and conducted panel activities
- Identified and evaluated further information sources
- Explored options for leveraging expertise related to use of generative AI
- Launched the redesigned patientsafety.pa.gov and addressed search engine optimization
- Disseminated resources to the patient outreach network to raise awareness and understanding of safe healthcare
- Developed an employee engagement committee and new programs
- Implemented PSA core values and communication plans
Guided by its vision of safe healthcare for all patients, PSA will advance Reimagine Patient Safety 2029 by diligently executing in-progress and planned Tactics, as well as undertaking additional Tactics as required.
Data Science & Research
Drawing from the Pennsylvania Patient Safety Reporting System (PA-PSRS)—a robust repository of over 5.8 million reports with hundreds of thousands of new submissions annually—the Data Science & Research (DS&R) team performs comprehensive analyses to identify important and emerging patient safety issues. These valuable insights are then disseminated throughout Pennsylvania and to the broader healthcare community.
Our primary channel for sharing these insights is Patient Safety, PSA’s internationally recognized, peer-reviewed journal reaching more than 234,800 readers worldwide. In 2025, the DS&R team led research projects and worked with partners to publish the following articles in Patient Safety:
- Long-Term Care Healthcare-Associated Infections in 2024: An Analysis of 26,501 Reports
- Patient Safety Trends in 2024: An Analysis of 315,418 Serious Events and Incidents From the Nation’s Largest Event Reporting Database
- 2024 Pennsylvania Patient Safety Reporting: Updated Rates for Acute Care Event Reports
- Wrong Drug Events Across Pennsylvania Healthcare Facilities: A Systematic Analysis of Medication Pairs, Class Patterns, and Clinical Safety Implications
- The Overlooked Threat of Hospital Falls During the Discharge Period: A Statewide Retrospective Analysis of Patient Safety Event Reports
- The Impact of Language Barriers on Patient Safety in Pennsylvania: A Review of 336 Patient Safety Events
Additionally, the team published 12 monthly newsletter articles featuring PA-PSRS reports.
- New Research Shows Discharge Window as High-Risk Period for Patient Falls
- Wrong-Route Errors Associated With Epinephrine to Treat Severe Type I Allergic Reactions
- Impact of Artificial Intelligence on Patient Safety Events: Preliminary Exploration of Events Reported to the PA-PSRS Database
- Strategies to Prevent Five-Fold Wrong Dose Errors With U-500 Insulin
- A Fatal Medication Error Involving Neuromuscular Blocking Agent and Insights From Wrong Drug Events in Pennsylvania
- Preventing Patient Burns and Skin Tears When Using Electrosurgical Units
- Improving Surgical Outcomes Through Frailty Screening: An Overview of the Risk Analysis Index
- Overcoming Communication Barriers to Improve Patient Safety for American Sign Language Users Who Are Deaf or Hard of Hearing
- Strategies for Mitigating Dofetilide-Induced Ventricular Arrhythmias
- Enhancing Patient Safety Surrounding Colonoscopy Procedures
- Beware of the Forgotten Tourniquet During Phlebotomy and IV Insertion
- Keeping Watch: Reviewing Recent Telemetry-Related Events in Pennsylvania Facilities
I AM PATIENT SAFETY
Executive Director’s Choice Award
Mollie Herlehy,
UPMC North Central PA Williamsport
A young trauma patient diagnosed with rib fractures, brachial injury, and C-spine fracture was experiencing cognitive deficits, which providers initially believed were related to a concussion. Speech pathologist Mollie Herlehy completed a comprehensive cognitive exam and advocated strongly for additional imaging. Once this was conducted, the team noted the patient had had several embolic strokes and a carotid dissection, requiring emergent transfer to a higher level of care. They acted quickly to provide appropriate treatment.
Ambulatory Care
St. Margaret Dermatology Clinic,
UPMC St. Margaret
With the goal of eliminating wrong-site surgeries, staff developed and implemented a comprehensive action plan that includes an enhanced time-out before each staging procedure, with visual reminders; real-time communication via headsets among surgical staff; and greater patient engagement, using larger handheld mirrors so patients can visually verify the surgical site alongside the provider. These process improvements have created a safer surgical environment and set a new standard for patient-centered safety practices in ambulatory dermatology care.
Runners-Up
- Colleen Berkery — Jefferson Surgical Center
- MASC Team — Monroeville Ambulatory Surgical Center
Commitment to Safety
Mobility Champion Team led by Jean Romano, Shawn Parsons, Sonya Wood-Johnson, and Lindsay Furlong,
GSPP Rehabilitation
GSPP Rehabilitation’s inpatient rehabilitation facility and long-term acute care hospital launched a Mobility Champion team of registered nurses, certified nursing assistants, therapists, and therapy aides to engage frontline clinicians and combine efforts collaboratively. Each champion serves as a peer mentor and change agent by using advanced knowledge, skills, and strategies to improve patient outcomes and reduce harm, focusing on one of three areas: safe patient handling and early mobility, pressure injury prevention, and fall reduction.
Runners-Up
- Surgical Services Department and Leadership (Operating Room) — Milton S. Hershey Medical Center
- Interdisciplinary Pressure Injury Reduction Team — WellSpan Good Samaritan Hospital
Healthcare Disparity
Lebanon County Crisis Intervention and Referral Services,
WellSpan Philhaven
To expand access to care outside of hospital settings and “meet people where they’re at,” the team shifted from reactive emergency responses to proactive,
compassionate engagement in the community. This resulted in a 68% increase in mobile crisis responses and a 44% increase in walk-in visits compared to the previous year. These efforts enabled them to intervene earlier, de-escalate crises more effectively, and guide individuals toward appropriate services—often without ED visits or inpatient hospitalization.
Runners-Up
- Sara Cohen/Women’s Health PAH — University of Pennsylvania Health System
- Adult Capillary Sampling Workgroup — Pennsylvania Hospital
Improving Diagnosis
CAUTI Prevention Team, Jefferson Einstein Philadelphia Hospital
To reduce clinically inappropriate urine cultures and improve diagnosis of urinary tract infections (UTIs), the team created a new urinalysis with reflex urine culture workflow and a clinical workflow in the electronic health record which prompts clinicians to assess and document symptoms of UTI and, if none are present, prompts cancellation of the urine studies. These tools reduced urine culture orders by 39.5% and improved the CAUTI standardized infection ratio and accuracy of UTI diagnoses.
Runners-Up
- Trauma Physical Therapy/Occupational Therapy Therapists, 5N Nursing Leadership, and Gerontology — Allegheny Health Network
- Andi Lint, Dr. Michael Desiderio, Lisa Sunyecz, Dr. Christine Flinn, Jessica Spiker, Stacy Pocius, Bill Johnson, Katie Tringhese, Janean Lubich, Andréa Atkinson, Heather Thompson, Dr. Ziad Dimachkie, Michelle Howard-Diggs, and Blair Lavake — WVU Medicine Uniontown Hospital
Individual Impact
Amanda Yingst,
Milton S. Hershey Medical Center
While providing preop instructions, nurse Amanda Yingst overheard escalating hostility from the patient’s significant other. Recognizing signs of potential domestic violence, she asked direct, supportive questions, and the patient disclosed she did not feel safe. Yingst said she would call back, ended the call to prevent further escalation, and notified the surgeon, who contacted local law enforcement for a welfare check and EMS transport to bring the patient to a safe environment and receive surgery.
Runners-Up
- Dr. Jeaninne Einfalt — Lehigh Valley Hospital-Cedar Crest
- Emily Rzodkiewicz — UPMC Hamot
Medication Safety
Heather Etzl and the Intensive Care Nursery Team,
Thomas Jefferson University Hospital
Barcode scanning of medications was frequently bypassed or manipulated to avoid disturbing infants, so Heather Etzl acquired tethers that attach to the ankle and display the barcode outside clothes or blankets, where they can be scanned without disturbance. The Intensive Care Nursery team received education on using them, underscored by stories of medication errors that proper barcode scanning could have prevented. Following implementation, the unit had two “good catches” where this process prevented medication errors.
Runners-Up
- Neil Wetcher — Lehigh Valley Hospital-Muhlenberg
- Diana Colonna and the Pediatric Intensive Care Unit Team — St. Christopher’s Hospital for Children
Patient Communication
Respectful Care Breakfast Team,
Pennsylvania Hospital
This multidisciplinary team introduced bimonthly breakfasts where postpartum patients can share their birth experiences with care providers such as nurses, physicians, and social workers, and hospital leadership. Patients have expressed appreciation for being heard in a nonclinical setting, and healthcare staff reported a renewed commitment to respectful maternity care and greater insight into patient needs. These sessions catalyzed changes in practice to address patient-identified gaps, such as signage for birthing parents separated from their newborns.
Runners-Up
- Medicine and Behavioral Health Clinical Effectiveness teams — Hospital of University of Pennsylvania
- Lindsey Morris and Jimmy Landy — UPMC Hamot
Safety Story
Shantel Thomas and Daniel Blum,
UPMC Memorial
During surgery, nurse Shantel Thomas and surgical technician Daniel Blum were performing their closing count when they identified that one laparotomy sponge was unaccounted for. The surgeon assured them that the sponge could not be inside the patient due to the presence of an open abdomen dressing. Thomas and Blum respectfully but firmly reiterated that their count was off and the sponge had to be located. The surgeon removed the dressing—and found the missing sponge.
Runners-Up
- The Philadelphia Campus Behavioral Health Clinician Team — Children’s Hospital of Philadelphia
- Dr. Vivek Ahya, Dr. Julie Uspal, and Patricia Macolino — Clinical Practices of the University of Pennsylvania
Transparency
Jefferson Abington and Lansdale Hospital Patient Safety & Quality Team, Jefferson Abington Hospital
This team launched a repository of stories from the Great Catch–Great Save Program, which recognizes staff for protecting patients and improving hospital systems. The intranet platform allows employees to view and share stories of near-miss events and resulting facilitywide improvements. Each entry describes not only the honoree’s actions, but also the “Safety Strategies and Behaviors” they employed—such as speaking up for safety and questioning and confirming—that directly contributed to the successful outcome.
Runners-Up
- Kenneth Miller, Kimberly Smith, Robert Leshko, Salvatore Maida, and Mark Lengvarsky — Lehigh Valley Health Network-Cedar Crest
- Oncology Medical Intensive Care Unit Team — Hospital of the University of Pennsylvania
FISCAL STATEMENTS and CONTRACTS
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 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 monies contributed by the healthcare industry, and (2) to ensure 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 2025, PSA received no contract funding.
A variety of analytical tools integrated within the design of PA-PSRS provide immediate and direct feedback to each facility on adverse event and near-miss reporting. Additionally, in 2025 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 and search engine optimization (SEO). PSA also 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.
Funding Received From Hospitals, Ambulatory Surgical Facilities, Birthing Centers, and Abortion Facilities
MCARE Act1 Section 305(c) set an initial Base Amount assessment payment of $5 million on acute care facilities in the first year of the MCARE Act beginning in 2002, with an annual increase based on the consumer price index (CPI) in each subsequent year. For fiscal year 2025–2026 (FY25–26), the MCARE 305(d) acute care maximum allowable assessment (MAA) totals $9,245,795, while the PSA Board authorized an FY25–26 acute care assessment totaling $7,055,000.
On December 9, 2025, PSA’s Board authorized FY25–26 acute care assessment surcharges totaling $7,055,000 and conveyed that amount to the department. The FY25–26 acute care assessment increased $255,000, or 3.8%, over the previous fiscal year.
In authorizing the FY25–26 acute care assessment amount, PSA’s Board considered several points, including the following:
- PSA’s FY25–26 budget totals $8.750 million. This is an increase of $430,000, or 5.2%, over the FY24–25 budget of $8.320 million.
- Of this $8.750 million budget, approximately $7.236 million is budgeted for acute care–related expenditures and funded with $7.055 million from FY25–26 acute care assessments. Acute care assessments also fund certain infection prevention activities within acute care facilities. These are separate and apart from Act 52 nursing home healthcare-associated infection (HAI) assessment–funded activities.
- At the December 9, 2025, Board meeting authorizing FY25–26 MCARE assessments, consideration was given to an expected $470,000 in investment income and a projected small budget surplus in FY25–26.
- Since the initial FY02–03 acute care assessment of $5.0 million pursuant to MCARE 305(c), the FY25–26 acute care assessment of $7.055 million represents a $2.055 million increase over 23 years, an average annual increase of 1.8%.
- FY25–26 assessment levels continue to provide PSA with liquidity and programmatic planning flexibility moving into the FY25–26 budget year.
Table 1 shows the number of acute care facilities assessed, authorized assessments, and assessment receipts for each fiscal year
Funding Received From Nursing Homes
Act 522 of the MCARE Act allows the DOH to assess Pennsylvania nursing homes through license surcharges up to an aggregate amount of $1 million per year for any one year beginning in 2008. An annual increase based on the CPI is made for each succeeding calendar year. This money can only be spent on activities related to nursing home HAIs. For FY25–26, the Act 52 nursing home MAA is $1,492,687.
On December 9, 2025, PSA’s Board authorized FY25–26 nursing home assessment surcharges totaling $1.245 million and conveyed that amount to DOH. The FY25–26 nursing home assessment increased $45,000, or 3.8%, over the FY24–25 nursing home assessment.
In authorizing the FY25–26 nursing home assessment amount, PSA’s Board considered several points, including the following:
- PSA’s FY25–26 budget totals $8.750 million. This is an increase of $430,000, or 5.2%, over the FY24-25 budget of $8.320 million.
- Of this $8.750 million budget, approximately $1.514 million is budgeted for nursing home–related expenditures and funded with $1.245 million from FY25–26 nursing home assessments.
- At the December 9, 2025, Board meeting authorizing FY25–26 MCARE assessments, consideration was given to an expected $470,000 in investment income and a projected small budget surplus in FY25–26.
- Since the initial FY08–09 nursing home assessment of $1.0 million pursuant to MCARE 409(b), the FY25–26 nursing home assessment of $1.245 million represents a $245,000 increase over 17 years, an average annual increase of 1.4%.
- FY25–26 assessment levels continue to provide PSA with liquidity and programmatic planning flexibility moving into the FY25–26 budget year.
Table 2 shows the number of nursing homes assessed, approved assessments, and assessments amounts received for each fiscal year.
Annual Expenditures and Non-Assessment Revenue Receipts
During calendar year 2025 (CY25), PSA spent about $7,797,323. In CY25, PSA received investment income of $517,727. PSA received no contract or service-related revenue in CY25.
Patient Safety Authority Contracts
The MCARE Act requires PSA to identify contracts entered into pursuant to the Act, including the amounts awarded to each contractor.
During CY25, PSA received services under the following contract Funds Commitments (FC):
Gainwell Technologies, LLC, FC# 4000028562
- July 1, 2024, through June 30, 2029
- Total Contract Amount: $7,521,530 over 5 years
- Amount invoiced in CY25: $1,387,692.14
- Five-year contract (including two option years) for Pennsylvania Patient Safety Reporting System (PA-PSRS) software development and maintenance and other IT services
Emergency Care Research Institute (ECRI), FC# 4000028616
- July 1, 2024, through June 30, 2029
- Total Contract Amount: $1,136,450 over 5 years
- Amount invoiced for CY25: $10,425.87
- Five-year contract (including two option years) for analyzing and evaluating patient safety data
Jennifer Ann Taylor, FC# 4000030436
- July 1, 2025, to June 30, 2026
- Total Contract Amount: $48,000
- Amount invoiced for CY25: $25,920
- Identification, classification, analysis, and reporting on existing automated patient safety software systems
Patient Safety Authority Balance Sheet
Table 4 reflects the status of the Patient Safety Trust Fund as of December 31, 2025.
Source: Office of Comptroller Operations, Commonwealth Bureau of Accounting and Financial Management. CY25 methodology includes an accrual of Board-approved FY25–26 Assessment Revenue.
Anonymous Reports/Referrals to Licensure Boards
Anonymous Reports
The MCARE Act allows healthcare workers to submit an “anonymous report.” Under the 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 PSA’s website and through PA-PSRS. PSA 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.
Patient safety advisors also review the anonymous reporting process with new patient safety officers as part of their onboarding program. Individuals completing the form do not need to identify themselves, and PSA assigns professional clinical staff to conduct any subsequent investigations. In 2025, PSA received 7 anonymous reports that met the MCARE Act requirements.
Referrals to Licensure Boards
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.
