AUTHOR BIOGRAPHY
Patient Safety Authority (patientsafety.pa.gov) is an independent state agency that oversees the Pennsylvania Patient Safety Reporting System (PA-PSRS), the largest database of its kind in the United States.
Abstract
Patient safety in Pennsylvania is largely directed by Pennsylvania’s Medical Care Availability and Reduction of Error (MCARE) Act, which requires some healthcare organizations to report incidents, serious events, and infrastructure failures (see MCARE for definitions) into the Pennsylvania Patient Safety Reporting System (PA-PSRS).1 Many variables, including the complexity of healthcare, impact reporting and create inconsistencies.
This is most evident in facility determination of serious events. Final Guidance2 developed by key stakeholders provides criteria for serious event classification, with the intent to create consistency in reporting among facilities. The PSA encourages the use of the Final Guidance, as well as the FAQs and Reporting Decision3 Tree, to help make determinations in reporting.
A recent review of PA-PSRS events related to returns to surgery uncovered opportunities for reinforcement related to two specific guidance principles, known complications and high risk.
Keywords
Pennsylvania, incidents, serious events, infrastructure failures, MCARE Act, known complications, high risk, return to surgery, event reporting
References
- Pennsylvania Department of Health. Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002). DOH website. 2002. Accessed June 2023. https://www.health.pa.gov/topics/Documents/Laws%20and%20Regulations/Act%2013%20of%202002.pdf
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Patient Safety Authority, Pennsylvania Department of Health. Final Guidance for Acute Healthcare Facility Determinations of Reporting Requirements Under the Medical Care Availability and Reduction of Error (MCARE) Act. Pennsylvania Bulletin. 2014;44(39):6178. https://www.pacodeandbulletin.gov/Display/pabull?file=/secure/pabulletin/data/vol44/44-39/2041.html
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Patient Safety Authority. Reporting Decision Tree: Serious Event, Incident, or Infrastructure Failure. PSA website. Accessed June 2023. https://patientsafety.pa.gov/pst/Documents/Resources%20for%20PSOs/EventReportingDecisionTree_.pdf
