Patient Safety in Acute and Ambulatory Care in 2025: Analysis of 326,672 Event Reports From Pennsylvania

ORCID iD  

Shawn Kepner (shawkepner@pa.gov) is a data scientist at the Patient Safety Authority (PSA). He is responsible for providing actionable insights using data science techniques and works with staff to focus resources and research in areas that have the greatest benefit to patient safety. He also serves as the data editor for Patient Safety, PSA’s award-winning, peer-reviewed journal.

*Corresponding author

Rebecca Jones, director of Data Science & Research for the Patient Safety Authority, leads a multidisciplinary team advancing patient safety through research that informs improvements in healthcare systems and delivers insights that bridge the gap between evidence and real-world practice. A registered nurse with a Master of Business Administration in healthcare management and certifications in patient safety, human factors, and risk management, she brings clinical experience, analytical expertise, and systems thinking to complex challenges. She has authored more than 40 peer-reviewed publications and contributed to national patient safety efforts with organizations such as the Institute for Healthcare Improvement, the National Quality Forum, and the Society to Improve Diagnosis in Medicine.

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, encompassing more than 5.8 million reports. Of these, over 5.3 million are housed in the acute care database, comprising reports submitted by acute and ambulatory healthcare facilities. In this article, we present data from reports submitted to the PA-PSRS acute care database in 2025, along with select data from prior years for comparison.

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).

In 2025, 326,672 reports were submitted to PA-PSRS, a 3.6% increase from 2024. Reports of serious events rose by 2.4%, while high harm events, a subset of serious events, decreased by 5.8%. Of all reports, 96.4% originated from hospitals and 3.6% from nonhospital facilities (ASFs, birthing centers, and abortion facilities). Incidents accounted for 96.0% of reports, and 4.0% were classified as serious events. Preliminary 2025 reporting rates show 32.0 reports per 1,000 patient days for hospitals and 10.9 reports per 1,000 surgical encounters for ASFs, with both rates decreasing by 0.5 points from 2024. Error Related to Procedure/Treatment/Test (P/T/T) remained the most frequently reported event type overall, representing 32.1% of all reports and 43.6% of reports from nonhospital facilities. Among serious events, Complication of P/T/T was the most common type, accounting for 55.4% of serious events overall and 72.5% from nonhospital facilities.

In 2025, total reports and serious event reports increased, while high harm reports decreased. Preliminary reporting rates for hospitals and ASFs decreased by 0.5 points from 2024. Apparent year-to-year changes may arise from reporting variation rather than broader shifts, underscoring the need to account for facility-level context and data quality limitations when interpreting statewide patient safety data. The Patient Safety Authority will continue working with Pennsylvania healthcare facilities to enhance reporting quality and promote patient safety.

In conjunction with the Patient Safety Authority’s 2025 annual report, PSA took a close look at the 326,672 incidents and serious events reported last year by hospitals, ambulatory surgical facilities (ASFs), birthing centers, and abortion facilities to the Pennsylvania Patient Safety Reporting System (PA-PSRS). The total number of reports increased 3.6% from 2024 to 2025, while preliminary reporting rates for hospitals (32.0 reports per 1,000 patient days) and ASFs (10.9 reports per 1,000 surgical encounters) decreased by 0.5 points from 2024. This comprehensive review and analysis of 2025 PA-PSRS reports may indicate that year-to-year changes can be attributed to variations in reporting rather than broader shifts. PSA will continue to work with Pennsylvania healthcare facilities to enhance the quality of event reporting.

Keywords: event report, annual report, incident, serious event, reporting rate, hospital, ambulatory surgery, abortion facility, birthing centers​