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Patient Safety Authority Issues Annual Report for 2005; Research from Mandatory Reporting Drives Change in Patient Care
[April 28, 2006]

Patient Safety Authority Issues Annual Report for 2005; Research from Mandatory Reporting Drives Change in Patient Care

(Comtex Business Via Thomson Dialog NewsEdge)HARRISBURG, Pa., Apr 28, 2006 (U.S. Newswire via COMTEX) --The Patient Safety Authority issued its Annual Report for 2005 with information indicating that meaningful improvements are being implemented in Pennsylvania healthcare facilities as a result of Act 13 (the "Mcare" Act) and the data received through the Pennsylvania Patient Safety Reporting System (PA-PSRS).

"The Authority continues working to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety," said Lorina Marshall-Blake, acting chair of the Authority's Board of Directors. "By disseminating information and clinical best practices, the Authority provides valuable feedback to healthcare professionals to help improve patient care."

Under Act 13 of 2002, all hospitals, birthing centers and ambulatory surgical facilities must submit reports of Serious Events (actual adverse events) and Incidents ("near-misses"). During the 2005 calendar year, facilities submitted a total of 169,072 reports, an increase of nearly 26 percent over 2004. Approximately 96 percent of these reports were Incidents that did not result in patient harm. The remaining 4 percent were Serious Events, in which the patient received some level of harm, ranging from minor, temporary harm to death.

Based on these reports, the Authority publishes the Patient Safety Advisory, a quarterly journal that provides clinical guidance to facilities about steps they can take to promote patient safety and reduce the potential for medical error. More than 60 scholarly articles about specific events submitted through PA-PSRS were published in 2005.

Nearly 75 percent of hospitals who responded to a recent statewide survey said they implemented changes as a result of information contained in the Patient Safety Advisory. This statistic is consistent with other findings that credit Act 13 with enhancing patient safety within Pennsylvania's healthcare facilities. At least 80 percent of healthcare executives surveyed said they believe the culture of safety has improved in their facility since the implementation of Act 13.

"Although this is only the first full year of statewide mandatory reporting, it appears that the Authority's work is having an impact on the delivery of care in Pennsylvania," said Alan B.K. Rabinowitz, administrator of the Patient Safety Authority. He noted the ultimate goal of the Authority is to develop a "culture of safety" in Pennsylvania where people and institutions encourage full and open disclosure to patients, acknowledging mistakes while implementing procedures to prevent future errors.

"Real improvement does not occur unless facilities are willing to take the necessary steps to change routines that may be compromising patient safety," said Rabinowitz.

Examples of the kinds of changes being implemented in hospitals and ambulatory surgical facilities as a result of Advisory articles include:

-- reducing the number of color-coded patient wristbands in use in their facility.

-- minimizing the risk of alcohol-based fires by using towels to catch alcohol runoff in the operating room.

-- educating surgeons about the importance of "time out" before surgery, in which the patient's identity and other critical elements of the procedure are reviewed.

-- adding to their list of prohibited abbreviations based on potentially confusing abbreviations identified in the Advisory.

-- educating staff on how to minimize the risk of anesthesia awareness.

A total of 440 healthcare facilities were subject to Act 13 reporting requirements in 2005. Hospitals accounted for 98.8 percent of all reports submitted. The most frequently reported events reported by hospitals involved medication errors and falls, while complications and errors from procedures, treatments or tests represented the most frequently reported events from ambulatory surgical facilities.

The average monthly number of reports submitted in 2005 showed an increase of almost 26 percent over reports submitted in 2004. Rabinowitz said that staff analysts attributed this increase to an improved adherence by healthcare facilities to Pennsylvania's mandatory reporting requirements, rather than to an increase of events occurring in those facilities.

"While these numbers and the survey responses document the effectiveness of mandatory reporting, they also demonstrate that there are real risks when any of us undergoes medical care," Rabinowitz said. "Certainly there is a lot more to do, and both facilities and individual providers must be vigilant in implementing all possible steps to assure quality outcomes and prevent patient harm."

An Executive Summary of the Annual Report is available on the Patient Safety Authority Web site at: psa(under)2005(under)annual(under)report(under)-(under)pr (under)&(under)exsum.pdf

The complete Annual Report for 2005 may be viewed on the Patient Safety Authority Website at: annual(under)report(under)for(under)2005(under)final (under)version.pdf

Additional information about the Patient Safety Authority, the PA-PSRS system and the Patient Safety Advisories, are accessible on the Authority's Web site,


The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error ("Mcare") Act, as amended by Act 88 of 2005. More than 450 hospitals, birthing centers and ambulatory surgical facilities are currently subject to Act 13 reporting requirements.

Facilities submit reports of serious events and incidents through the Pennsylvania Patient Safety Reporting System (PA- PSRS), a confidential Web-based system that was developed for the Authority under a contract with ECRI, a Pennsylvania-based independent, non-profit health services research agency, in partnership with EDS, a leading international, information technology firm, and the Institute for Safe Medication Practices (ISMP), also a Pennsylvania-based, non-profit health research organization.

More than 300,000 reports have been submitted through PA-PSRS since the program was initiated in June 2004. Based on those reports, the Authority issues quarterly and supplementary Patient Safety Advisories to advise hospitals, other healthcare facilities and individual providers about steps they can take to reduce and prevent patient harm. The PA-PSRS system also provides facility managers with sophisticated analytical tools that enable them to evaluate data about their own facilities. They can use this information for internal patient safety, risk management and quality improvement activities.

Laurene M. Baker of the Patient Safety Authority,

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