Patient Safety in Pennsylvania Healthcare Facilities

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Patient Safety in Pennsylvania Healthcare Facilities

Pa Patient Saf Advis 2009 Jun;6(2):72.

Since inception of the Pennsylvania Patient Safety Authority’s reporting system in 2004, the most challenging question asked of the Authority has been whether healthcare in Pennsylvania is becoming safer. To complement its efforts toward this goal, in January 2009, the Authority invited patient safety officers (PSOs) from all reporting facilities in Pennsylvania to participate in a survey initiative to measure the level of adoption of selected safety practices. PSOs from 200 of 525 invited facilities completed the survey, including 118 hospitals (59%), 80 ambulatory surgical facilities (40%), 1 birthing center (0.5%), and 1 abortion facility (0.5%).

The 37 safety practices were organized into the domains of leadership (4 practices), medication (11 practices), safe surgery (7 practices), infection control (3 practices), device safety (6 practices), patient identification (2 practices), transition of care (1 practice), environment (1 practice), care management (1 practice), and falls prevention (1 practice). Practices were defined according to the Centers for Medicare & Medicaid Services, the Joint Commission, and the National Quality Forum and associated with the specific Pennsylvania Patient Safety Advisory articles that advocated them.

Examples of the aggregate results of adopted safety practices under different domains include the following (certain practices may not apply to all facility types):

Leadership. Written instructions for staff about error reporting that include that “just culture” principles are fully implemented throughout the organization (60.5% of participating facilities).

Medication. The organization has established explicit mandatory elements of a telephone or verbal order that includes the use of read-back (83% of participating facilities).

Safe surgery. The organization requires both that the patient (or representative) is involved in confirming the surgical site and that the surgical site mark is made before the patient is sedated (79.5% of participating facilities).

Infection control. An infection control plan that specifies the inspection frequency of patient care areas for handwashing capabilities and availability of supplies is fully implemented throughout the organization (79% of all participating facilities).

Device safety. Prohibition of defibrillator use for routine physiologic monitoring is fully implemented throughout the organization (69% of participating facilities).

Limitations of the survey include that results represent about 38% of reporting facilities in Pennsylvania and may not reflect statewide adoption of practices or may disproportionately represent facilities. Varying interpretation of questions among the participating PSOs may have occurred. Finally, generalizing results from birthing centers and abortion facilities is not possible because of the low response from these facility types.

In May 2009, PSOs and chief executive officers of participating facilities received a detailed report of survey results comparing the level of adoption of the practices at their facilities with that of similar facilities statewide. The aggregate results of the survey were discussed in the Authority’s 2008 annual report. The detailed aggregate results, a sample action agenda to assess organizational assessment and schedule required actions, and links to associated Advisory articles, are also available from the Authority at http://www.patientsafetyauthority.org/
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	THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS
	The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .
	ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.
	The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.