AUTHOR BIOGRAPHIES
Christine E. Sanchez, MPH. Patient Safety Authority
Christine E. Sanchez (chrsanchez@pa.gov) is a patient safety analyst on the Data Science and Research team at the Patient Safety Authority (PSA). She is responsible for utilizing patient safety data, combined with relevant literature, to develop strategies aimed at improving patient safety in Pennsylvania.
Matthew A. Taylor, PhD, Patient Safety Authority
Matthew A. Taylor is a patient safety analyst for the Patient Safety Authority (PSA), where he conducts research, uses data to identify patient safety concerns and trends, and develops tools and materials to help facilities and clinicians improve patient safety.
Rebecca Jones, MBA, RN, Patient Safety Authority
Rebecca Jones is director of Data Science and Research at the Patient Safety Authority (PSA) and founder and director of the PSA’s Center of Excellence for Improving Diagnosis.
Abstract
Background: Previous research has shown that visitors can decrease the risk of patient harm; however, the potential to increase the risk of patient harm has been understudied.
Methods: We queried the Pennsylvania Patient Safety Reporting System database to identify event reports that described visitor behaviors contributing to either a decreased or increased risk of patient harm. Event reports from January 1 to June 30, 2019, were searched for keywords and reviewed for inclusion criteria. Event reports were manually coded to identify visitor influence on risk of patient harm (e.g., increase or decrease), visitor behavior, and event type.
Results: A total of 427 event reports were analyzed and we identified five categories of visitor behavior that influenced patient safety by either decreasing or increasing the risk of patient harm. We found that 63.7% (272 of 427) of event reports described a visitor behavior that decreased the risk of patient harm and the remaining 36.3% (155 of 427) of reports described behavior that increased the risk
of harm. There was a greater variety of visitor behaviors that contributed to an increased risk of patient harm, as opposed to a decreased risk of harm. The visitor behavior most frequently associated with a decreased risk of patient harm was a PA-PSRS is a secure, web-based system through which Pennsylvania hospitals, ambulatory surgical facilities, abortion facilities, and birthing centers submit reports of patient safety–related incidents and serious events in accordance with mandatory reporting laws outlined in the Medical Care Availability and Reduction of Error (MCARE) Act (Act 13 of 2002).42 All reports submitted through PA-PSRS are confidential and no information about individual facilities or providers is made public. communicating with staff (91.2%, 248 of 272); for example, to inform staff of deterioration of a patient’s condition. The visitor behavior most frequently associated with an increased risk of patient harm was moving a patient (63.2%, 98 of 155). Across the 427 event reports, we found that visitor behavior was associated with seven event types; the falls event type (61.6%, 263 of 427) and medication-related event type (14.8%, 63 of 427) occurred most frequently.
Conclusion: The current study provides insight into which visitor behaviors are contributing to a decreased risk of patient harm and adds to the literature by identifying behaviors that can increase the risk of patient harm, across multiple event types. Table 6 and Table 7 outline potential safety strategies that staff and facilities may consider using to target visitor behavior. As outlined in Table 6, the use of warning and instructional signage can be a relatively low-effort and effective strategy to influence visitor behavior and address multiple behavior categories and event types.
