AUTHOR BIOGRAPHIES
Shawn Kepner, MS, Patient Safety Authority
Shawn Kepner (shawkepner@pa.gov) is a data scientist at the Patient Safety Authority.
*Corresponding author
Rebecca Jones, MBA, RN, Patient Safety Authority
Rebecca Jones is director of Data Science & Research at the Patient Safety Authority (PSA).
ABSTRACT
Background
The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest patient safety data repository of its kind in the United States and one of the largest globally, housing over 5 million reports submitted since 2004. In this article, we present data from reports submitted to PA-PSRS in 2024.
Methods
We used data extracted from PA-PSRS and obtained from the Pennsylvania Health Care Cost Containment Council (PHC4). Report counts are based on the date the report was submitted, while reporting rates are calculated using the event occurrence date. Rates are expressed per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs).
Results
In 2024, 315,418 reports were submitted to PA-PSRS, marking a 9.5% increase from 2023. Reports of serious events rose by 7.3%, while high harm events increased by 1.1%. Of all reports, 96.0% came from hospitals, while 4.0% originated from nonhospital facilities (ASFs, birthing centers, and abortion facilities). The vast majority (96.0%) were incidents, while the remaining 4.0% were classified as serious events. Preliminary 2024 reporting rates show 32.2 reports per 1,000 patient days for hospitals and 11.4 reports per 1,000 surgical encounters for ASFs, with both rates increasing by 1.1 points from 2023. Error Related to Procedure/Treatment/Test (P/T/T) remained the most frequently reported event type overall, accounting for 33.4% of reports from all facilities combined and 47.6% from nonhospital facilities. Among serious events, Complication of P/T/T was the most common type, making up 57.7% of serious event reports from all facilities combined and 71.4% from nonhospital facilities.
Conclusion
In 2024, the total number of reports, serious event reports, and high harm event reports increased, as did the preliminary reporting rates for hospitals and ASFs. The Patient Safety Authority will continue working with Pennsylvania healthcare facilities to enhance reporting quality and promote patient safety.
