About Us

Collaborative Strategies to Improve Patient Safety

The Pennsylvania Patient Safety Authority (PSA) has formed collaborative partnerships with organizations and facilities to improve patient safety and quality and meet PSAs vision of “Safe healthcare for all patients.”

Collaboration is an important foundational service that is offered by PSA. Collaborations offer partnerships, learning opportunities, successful improvements, and help facilities align to focus on specific topics to prevent harm and improve patient safety.  .

If you have questions about any of our collaborations please contact the Patient Safety Authority at 717-346-0469 or patientsafetyauthority@pa.gov.

Hospital and Healthsystem Association of Pennsylvania Hospital Improvement Innovation Network

On September 28, 2016, HAP was awarded one of the 16 primary federal contracts for HIIN. The Patient Safety Authority has formed partnerships with HAP and other Pennsylvania healthcare organizations to work with Pennsylvania hospitals to reduce healthcare-acquired conditions. The goals of the HIIN are to achieve the following:

  • A 20% decrease in overall patient harm.
  • A 12% reduction in 30-day readmissions as a population-based measure from 2014 baseline.

The Authority’s success in previous partnerships with HAP has led to the leadership of the Authority on the adverse drug events, prevention of falls with harm, and culture of safety projects. The Authority is also leading a project with the Health Care Improvement Foundation to reduce emergency department radiologic diagnostic errors. The Authority issued a press release, "The Authority to Focus on Four Patient Safety Areas," in November 2016 that can be found on the Authority’s website.

The analyses upon which this publication is based were performed under Contract Number HHSM-500-2016-00066C, entitled, "Partnership for Patients Hospital Improvement Innovation Network Contract, sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services."

Preventing Wrong-Site Anesthesia Nerve Blocks 

Wrong-site local and regional anesthesia nerve blocks represent a significant portion of wrong-site operating room procedures. Between July 1, 2004, and December 31, 2016, wrong-site nerve blocks performed by anesthesiologists and surgeons comprised 25.9% of all wrong-site procedures reported through PA-PSRS. Given that only a fraction of patients who are vulnerable to wrong-site surgery receive anesthesia in the form of blocks, the proportion of wrong-site anesthesia blocks is notable.

The Patient Safety Authority has partnered with the Pennsylvania Society of Anesthesiologists for the following:

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

PSA Resident Safety Program for Antibiotic Stewardship in Long-Term Care

In September 2017, the Patient Safety Authority began a collaboration with long-term care facilities to reduce overall antibiotic use and create an antibiotic stewardship program. Thirty long-term care facilities participated in the program. The program will conclude in the fall of 2018, at which time the facilities will have:

  • Developed and sustained a multidisciplinary antibiotic stewardship workgroup
  • Incorporated antibiotic stewardship into the infection control plan, policies, procedures, and QAPI program
  • Implemented a stewardship education and communication program for clinicians, residents and families
  • Leveraged monitoring and tracking outcomes to improve optimal antibiotic usage
  • Made use of stewardship tools to sustain improvements

Completed Collaborative Projects

The Patient Safety Authority has completed successful collaborations that have reduced falls with harm, phlebotomy mislabeling events, wrong-site surgeries, day of surgery cancellations and transfers to acute care, and long-term care catheter associated urinary tract infections. Tools can be found under Patient Safety Topics and additional information can be found in our Annual Reports.

  • Agency for Healthcare Research and Quality (AHRQ) Safety Program for Long-Term Care: HAIs/CAUTI
  • Ambulatory Surgical Facility Perioperative Screening and Assessment Collaboration
  • Comprehensive Unit-based Safety Program to Reduce Central Line-Associated Blood Stream infections with the Hospital and Healthsystem Association of Pennsylvania
  • Delaware Valley Falls Reduction with The Health Care Improvement Foundation
  • Delaware Valley Wrong-Site Surgery Prevention with The Health Care Improvement Foundation
  • PA - NSQIP, National Surgical Quality Improvement Program
  • Phlebotomy Specimen Labeling
  • Western Pa. Surgical Site Infection Prevention Collaborative (WSSI)
  • Hospital and Healthsystem Association of Pennsylvania (HAP) Hospital Engagement Network 1.0 and 2.0*:

    • Falls Reduction and Prevention
    • Preventing harmful ADE related to anticoagulants, insulin and opioids
    • Preventing Wrong-Site Surgery
    • Culture of Safety Education
    • Assisted with HAPs HAI projects

The analyses upon which this publication is based were performed under Contract Number HHSM-500-2015-00300C, entitled, "Partnership for Patients Hospital Engagement 2.0 Contract."