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The Pennsylvania Patient Safety Authority recognizes the significant strides in patient safety improvement made by Pennsylvania healthcare facilities, as well as the important work that remains. In 2016, the Authority published a study of the effectiveness of data collection, data analysis, information dissemination, and statewide collaborative learning by the Authority and its partners to reduce healthcare-associated patient harm in the Commonwealth. In the five measures selected for analysis, these core patient safety efforts led to an estimated 2,600 lives saved and $147 million saved since 2004.
The Authority, an independent state agency established under the Medical Care Availability and Reduction of Error (MCARE) Act1 of 2002, collects and analyzes data reported through its Pennsylvania Patient Safety Reporting System (PA-PSRS) and then provides strategies and lessons learned to healthcare facilities to improve safety and help prevent patient harm.
Under the MCARE Act, healthcare facilities must report Serious Events (events that harm the patient) and Incidents or “near misses” (events that do not harm the patient) to the Authority. Facilities must notify patients or their families when a Serious Event has occurred. The Pennsylvania Department of Health also receives Serious Event reports for its regulatory role.
The Authority initiated statewide mandatory reporting in June 2004. All reports are confidential and non-discoverable. In 2007, MCARE was amended (Act No. 2007-52: Reduction and Prevention of Health Care-Associated Infection and Long-Term Care Nursing Facilities2) for nursing homes to report healthcare-associated infections (HAIs) as Serious Events to the Authority.
This executive summary highlights the Authority’s 2016 activities; specific details are included in the corresponding sections of the overall annual report.
A change in leadership occurred in 2016, as former executive director Michael C. Doering retired. The Board of Directors named Regina M. Hoffman as executive director in March 2016. The board and staff engaged in the Authority’s third strategic planning process, in which participants developed a mission statement, vision, and four strategic pathways of focus on (1) improving diagnosis, (2) the patient, (3) long-term care, and (4) evaluating the reporting system. It is important to address these pathways while continuing the foundational efforts of data collection and analysis, information dissemination, education, and collaborative learning.
The aforementioned analysis about the value of patient safety improvement efforts in Pennsylvania also discusses the decrease in high-harm events (i.e., Serious Events that result in permanent harm, near death, or death), a trend that continues in events reported during 2016. Acute healthcare facilities reported 255,714 events, with an increasing percentage of events reported as Incidents (n = 248,166), rather than Serious Events (n = 7,548). This brings the total number of events reported (2004 through 2016) to 2.76 million. The reporting category, Error related to Procedure/Treatment/Test, continues to be the most common category of Incident reports, and Complication of Procedure/Treatment/Test the most common category of Serious Events. Of Serious Events, facilities reported 218 events that may have contributed to or resulted in a patient’s death, a 13.8% decrease from 2015 as well as an overall decrease from 2005 through 2016.
Staff and board members, as well as participants from other agencies and organizations in the Commonwealth, engaged in efforts to improve consistency in acute healthcare facility event reporting with standards effected in April 2015. In 2016, the Authority observed positive indicators associated with these standardization efforts, including improvement in Serious Event reporting, a near doubling of events reported under the new and revised event types and subtypes, and continued participation by reporting facilities in education about standardization principles.
Nursing homes reported 27,544 HAI events in 2016, a 13% decrease from the previous year. The year 2016 represents the second full year of data since revised reporting criteria was implemented in 2014. Some highlights of 2016 event data include that catheter-associated urinary tract infections (CAUTIs) continue to be the predominant urinary tract infection by pooled infection rate, gastrointestinal infection reports decreased (statistically significant) compared with such reports in 2015, and reports of influenza in Pennsylvania align with nationally reported data.
Events reported by Pennsylvania healthcare facilities, requests for information from Pennsylvania healthcare providers, and review of the medical and patient safety literature prompts analysis of the aggregate event reports. This leads to dissemination of analysis and guidance through the Authority’s journal, the Pennsylvania Patient Safety Advisory. From the first issue in March 2004 through December 2016, the Advisory has provided nearly 540 safety-focused articles and nearly 50 associated “toolkits” of assessment tools and education, available at www.patientsafetyauthority.org. To date, Pennsylvania healthcare facilities credit the Advisory with contributing to more than 4,650 structure and process improvements. Topics addressed during 2016 include surgical procedures, medication-related events, infection prevention, maternity, leadership, patient/family involvement, and teamwork.
Of the Authority’s website traffic in 2016 (n = 1,563,044 hits) Advisory articles and toolkits comprised the majority, with 753,893 and 145,548 hits, respectively.
Staff—including patient safety liaisons (PSLs), patient safety analysts, infection prevention analysts, and physicians—as well as patient safety and subject matter experts, use the Authority’s analysis, disseminated information, and additional research to educate healthcare providers about patient safety strategies. In 2016, educational programs were associated with education of nearly 4,000 participants onsite at healthcare facilities, nearly 1,800 through regional/other presentations, nearly 4,000 through webinars, and nearly 800 through the Authority’s online education system. The Authority further enhanced its PSL outreach to reporting facilities with “Keystones” (i.e., targeted, topical outreach to facilities accompanied by consultative tools and resources).
In its work to reduce HAIs, the Authority’s infection prevention staff educated participants during activities mentioned above. Staff researched and published educational and assessment tools (e.g., accompanying Advisory articles) to address reported HAI events; in feedback, hospital and nursing home representatives reported that these tools were highly useful in increasing staff knowledge and identifying specific areas of focus for prevention efforts. Furthermore, staff continued work with the Pennsylvania Department of Health, the Hospital and Healthsystem Association of Pennsylvania (HAP), and local health departments to help Pennsylvania acute healthcare facilities prepare for episodic biological threats by providing consultation associated with site visits.
The Authority has long recognized the value of collaborative learning and continued its focus on such improvement efforts in 2016. Staff concluded work with HAP on Hospital Engagement Network (HEN) 2.0 immersion projects, addressing falls with harm and adverse drug events, as well as HAIs. Success in HEN 2.0 and during previous contracts led to the Authority again working with HAP, which was awarded a primary federal contract for the Hospital Improvement Innovation Network (HIIN) in September 2016. The Authority is leading HIIN projects addressing adverse drug events, falls, and culture of safety. The Authority is also co-leading a HIIN project with the Health Care Improvement Foundation to reduce emergency department radiologic diagnostic errors.
Finally, healthcare facilities again had the opportunity to showcase commitment to patient safety and reward the people involved through the annual “I Am Patient Safety” contest. The Authority recognized 14 individuals or groups from nominations from Pennsylvania facilities, all of whom are featured in this annual report.
The Authority recognizes that Pennsylvania healthcare facilities bear financial responsibility for costs associated with complying with mandatory reporting requirements. The Authority focuses on two fiscal goals: (1) to be prudent in the use of moneys contributed by the healthcare industry, and (2) to assure that healthcare facilities paying for PA-PSRS receive direct benefits from the system and Authority programs. The Authority’s FY 2016–2017 budget totals $8.5 million, with approximately $7.2 million funding expenditures other than for HAI programs.
The Authority remains strongly committed to its foundational patient safety efforts, as evidenced by its continued attention to and enhancement of its data collection and analysis, information dissemination, education efforts, and collaborative learning outputs. Innovation is key to ongoing success, a critical concept for both the Authority’s foundational efforts and its forthcoming strategic pathways to enhance patient safety for all patients in the Commonwealth.
- Medical Care Availability and Reduction of Error (MCARE) Act of March 20, 2002, P.L. 154, No. 13, Cl. 40. Available: http://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2002&sessInd=0&act=13.
- Medical Care Availability and Reduction of Error (MCARE) Act - Reduction and Prevention of Health Care-Associated Infection and Long-Term Care Nursing Facilities Act of July 20, 2007, P.L. 331, No. 52, Cl. 40. http://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2007&sessInd=0&act=52.
See the complete annual report
Executive Summary (interactive)
Authority Partnerships (interactive)