Thursday, May 1, 2008

Patient Safety Authority Issues Annual Report for 2007

April 30, 2008
Contact: Laurene M. Baker
Patient Safety Authority
(717) 346-1092

Patient Safety Authority Issues Annual Report for 2007

The Authority in 2007 developed and began implementing a Strategic Plan while facilities continued to use guidance in Patient Safety Advisories to improve patient safety while implementation of Act 52 to eliminate infections in hospitals and nursing homes began

HARRISBURG: The Pennsylvania Patient Safety Authority released its 2007 Annual Report today outlining its Strategic Plan that aligns its activities more closely with its educational and quality improvement mission. Also, facilities increased reporting and continued to make changes based on guidance in Patient Safety Advisories.

"The Patient Safety Authority had a full year last year and this year will be just as active if not more so," Mike Doering, executive director of the Pennsylvania Patient Safety Authority said.
"The initiatives in our Strategic Plan once fully implemented will help to improve patient safety in Pennsylvania."

The plan increases the Authority’s focus on education and collaboration and identifies several multi-year initiatives, some of which were developed based on feedback from focus groups held with Pennsylvania Patient Safety Officers. Selected initiatives are aimed at educating Boards of Trustees in their role in promoting patient safety, creating an online forum for more routine sharing of best practices and lessons learned among Patient Safety Officers and creating a Patient Safety Liaison pilot program that will offer healthcare facilities on-site education or quality improvement assistance from the Patient Safety Authority.

Other immediate plans for the Authority include hiring a Director of Educational Programs. The Director of Educational Programs will direct the Authority’s statewide and regional education and training programs and help develop educational materials for facilities to utilize. This person would also supervise the regional Patient Safety Liaisons.

"Many Patient Safety Officers have asked for more of a presence from the Patient Safety Authority to help them implement patient safety initiatives," Doering said. "We recognize that while every facility shares the same goal to improve patient safety, each facility faces different obstacles in achieving that goal. These new Authority employees will work with facilities on a more individual basis to help them achieve their patient safety goals."

Doering added that several of the initiatives require collaboration with other healthcare and state entities.

"We’re working with the Hospital and HealthSystem Association to implement a pilot program to educate hospital trustees and top-line management and we’ve been working with the Department of Health, Governor’s Office of Healthcare Reform and Pennsylvania Healthcare Cost Containment Council to implement Act fifty-two to reduce and eliminate healthcare associated infections," Doering said.

Through Act 52 the Authority established a 15-member panel of infection control experts throughout Pennsylvania. The panel has been instrumental in providing guidance for the Authority and Department of Health in determining the reportable infection events for hospitals and nursing homes. The Authority plans to use the panel to assist in identifying training and education activities that will reduce and eliminate healthcare associated infections.

Another initiative in the plan will allow Pennsylvania’s Patient Safety Officers to share best practices and other information through a confidential electronic forum so they can learn from one another more directly.

"So many facilities are developing and implementing great programs to improve patient safety," Doering said. "Our goal is to help them share the information instead of having each facility reinvent the wheel."

The Authority will also work towards improving the consistency in the number of reports received through PA-PSRS. The data in the 2007 Annual Report shows that there is substantial variation in the number of reports submitted by different healthcare facilities. While a vast majority of hospitals are reporting Serious Events (events that cause harm to the patient) and Incidents (events that do not cause harm to the patient); the volume varies greatly from facility to facility.

Doering said the Authority believes the main reason facilities are reporting inconsistently is because there are differences among them regarding how to interpret language in Act 13 as to what is reportable. He added that the Authority will work with the Department of Health, which is the state regulator of reporting, to offer facilities more guidance as to what should be reported to bridge the gap in facility reporting levels. The inconsistency is of concern to the Authority.
"These differences in reporting by different types of facilities is concerning for several reasons," Doering said. "If events aren’t reported, we may be missing opportunities to share information that could help to prevent similar events from happening in other facilities."

"Another concern is that when facilities have different interpretations of the Serious Event definition, a patient who would receive written notification if they were harmed in one facility might not be notified if they were in another facility," Doering added. "It is important for open communication to occur between the patient and provider when a Serious Event occurs so that everyone understands what happened."

He explains that according to Act 13 when a Serious Event occurs in a facility the patient that suffered from the Serious Event must receive written notification from the facility explaining what happened. The provision was added in Act 13 to encourage providers to communicate more openly with their patients.

Doering said many facilities have been asking for further guidance about reporting. The Authority has provided facilities with program memoranda to help them interpret what should be reported. (e.g. Facilities should not consider an event as not reportable simply because it is listed on the patient consent form as a possible occurrence.)

Since these efforts have not proven to substantially decrease reporting variability, Doering said the Authority has made standardization a goal in its 2007 Strategic Plan which can be found on page 14 in its annual report (link below).

To accomplish this goal, the Authority will do the following:
• We will work with the Department of Health to explore both organizations’ interpretations of Act 13 requirements, with the goal of providing interpretive guidance that can be used by facility Patient Safety Committees and Department of Health surveyors.
• We are working with healthcare facilities in the Delaware Valley through the Health Care Improvement Foundation to improve reporting consistency for selected types of events.
• We will give guidance to healthcare providers on disclosure of adverse events to patients and their families.
• We will perform a comparative analysis of healthcare facilities that are high-and low-volume reporters in an effort to determine what organizational characteristics encourage a greater level of reporting. We will distribute our findings through the Pennsylvania Patient Safety Advisory.
• A consumer tips sheet is available to further educate patients on the Authority and what is a Serious Event and Incident.

Also in the 2007 Annual Report is the executive summary that gives readers a breakdown of what is contained in the report in a nutshell. As mentioned, more reports were submitted in 2007 than any other previous year. An Advisory article highlighting the problem with wrong-site surgeries made national news and continues to garner interest in the healthcare community. The Authority also continued to offer educational toolkits and consumer tips sheets with each Advisory for further guidance. A Failure Mode and Effects Analysis course was also offered in 2007 to educate facilities on how to examine their current processes for any potential gaps that could cause a Serious Event or Incident.

An Executive Summary of the 2007 Annual Report is attached to this press release. For the complete 2007 Annual Report, go to, or click on the following link

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