This newsletter is now biweekly, to better deliver timely information, tools, and resources you can use to keep patients and staff safe. Each issue also includes details about our upcoming events and webinars, as well as stories that highlight the power of event reporting in informing and inspiring change throughout healthcare systems and facilities.
Patient Safety Authority (PSA) staff review reports of unplanned returns to the operating room (OR). Many of these events are incorrectly reported as incidents.
If an injury occurs related to the clinical care of the patient in the healthcare facility—and the patient needs additional healthcare services, including a return to the OR—this is a serious event.
See an example here.
Planned returns to the OR: For example, a scheduled two-part procedure is not reportable (as an incident or serious event).
Additionally, if a patient is at higher-than-normal risk of returning to the OR, or if returning to the OR is expected to occur frequently for a particular procedure, this is not reportable. However, the patient must be made aware of this higher risk, and it must be documented.
While failing to report a serious event violates the Medical Care Availability and Reduction of Error (MCARE) Act, submitting nonreportable events into the Pennsylvania Patient Safety Reporting System (PA-PSRS) is also problematic.
Submitting a report when a patient safety event did not occur (e.g., the scheduled two-part procedure) artificially inflates the number of patients returning to the OR.
This could make your organization appear less safe than it is—especially if you were asked to produce a raw aggregate list.
Please contact your patient safety liaison if you have ANY questions about whether an event is reportable.
EVENT REPORTING STORIES
Pennsylvania hospitals are required to report patient safety events, but do you know why it’s so important? Event reports can be the first indication of underlying problems, regardless of whether harm occurs. They can be tools to trigger widespread change facilitywide—or even nationwide.
Below is the story of how reporting an event prompted change to improve patient safety throughout a health system.
Root Cause Analysis reveals deeper Medication Reconciliation Issue.
A safety event involving a discharged patient taking too much of a prescribed medication prompted a facility’s liver transplant and clinical leadership teams to perform a root cause analysis. They identified a significant contributing factor to the event: Each transplant service (e.g., lung,liver, etc.) had a different medication reconciliation process upon discharge. Teams from each transplant service and an interprofessional team (including physicians; nurses; pharmacists; advanced practice nurses; Nursing administration and management; case management; and managers from Regulatory, Quality and Patient Safety) collaborated to establish a standardized process for medication reconciliation upon discharge.
