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Patient Safety Authority
333 Market Street
Lobby Level
Harrisburg, PA 17120

Phone: 717-346-0469
Fax: 717-346-1090

Driving Change Through Collaborations 
Collaborations Image 
Driving Change Through Collaborations 

Through collaborations, the Patient Safety Authority can help Pennsylvania healthcare facilities take their knowledge and expertise to the next level by working with each other to prevent medical errors and improve patient safety. Listed below are several collaborations that are either ongoing or have been completed in areas such as: wrong-site surgery, mislabeling blood specimen events, harmful falls, surgical-site infections, central-line associated bloodstream infections (CLABSI) and adverse drug events. If your facility would like to join any of the ongoing collaborations or have an idea for one, please contact your Patient Safety Liaison.  

Ambulatory Surgical Facility Perioperative Screening and Assessment Collaboration

The Pennsylvania Patient Safety Authority (Authority) and eleven participating Ambulatory Surgical Facilities (ASFs) are working together in a collaboration intended to strengthen and improve patient safety by improving the preoperative screening and assessment of patients in ASFs.  The Authority has developed and is implementing a strategic and cohesive program that provides education, tools, technical assistance, resources, and an interactive forum to demonstrate an improvement in the screening and assessment of patients undergoing ambulatory surgery by showing a decrease in the rate of procedure cancellations and transfers and admissions to an acute care facility.  Studies associate both of these outcomes with the need for appropriate patient screening and selection and pre-operative planning.

The scope of the ASF Preoperative Screening and Assessment Collaboration is as follows:

  • A statewide needs assessment to identify potential contributing factors to procedure cancellations, transfers and admissions.
  • Development and implementation of a series of workshops based on needs assessment results and best practices that provide education, tools, technical assistance, resources, and interactive forums focusing on the preoperative screening and assessment process.
  • Creation of a collaborative learning network.
  • Education for ASF teams using medical literature, the Authority’s database information, and other pertinent educational resources regarding patient screening and assessment in ASFs.
  • Dedication of a shared website to collect data, share resources and document all activities in this endeavor.
  • Guidance, assistance, and technical support for all participating ASFs.

The Authority will gather three months of baseline data and twelve months of compliance monitoring data. Each participating ASF will complete and submit the following information which will be collected and analyzed by the Authority:

  • Monthly outcome measure data collection form.
  • Event Investigation data collection form.

The outcome measures are the rate of procedure cancellations and the rate of transfer and admissions to an acute care facility. Quarterly facility-specific reports will be provided to all participants that can be used to identify vulnerabilities, or areas that require further effort and improvement. The reports will provide a basis for future comparison. Results of the collaboration will be published in the Advisory so that other facilities throughout the state may benefit from collaboration learning. 

PA - NSQIP, National Surgical Quality Improvement Program

The purpose of the collaborative is to reduce infections by identifying how successful hospitals have already done so by extending the SSI bundle already in use and obtaining compliance with best practices, and then transferring those lessons to other facilities.

  • The collaborative team has developed a Surgical Site Infection Prevention Best Practice assessment tool based on the American College of Surgeon’s Best Practices and information collected from facility best practice.
  • Site visits were conducted with 4 facilities in December and January utilizing the assessment tool.  These were facilitated by a surgeon, a nurse, and a PSA representative and included interviews with surgeons, anesthesia, OR directors, PACU, Pre-Op, and Intra Op, and Inpatient nurses.
  • The survey team met to review the results and potential interventions are being evaluated for implementation by the facilities.

Western Pa. Surgical Site Infection Prevention Collaborative (WSSI) 

The Authority, in partnership with the Three Rivers Association of Professionals in Infection Control, the National Association of Professionals in Infection Control, and the Pennsylvania Department of Health initiated and facilitated a collaboration developed to promote evidence-based strategies to reduce SSIs in western Pennsylvania and to establish a list of measures to track and benchmark SSIs. The project aimed to expand the bundle of best practices advocated by the Surgical Care Improvement Project. A total of 23 facilities joined the collaborative, including two ambulatory surgery centers. The data collection was facilitated through a dedicated collaborative site on PassKey provided and maintained by the Authority. The final data collection and summary will take place in 2012.

Central Line-Associated Blood Stream Infections:
In collaboration with HAP, the PSLs and infection control analysts are involved with the Comprehensive Unit-based Safety Program (CUSP) and Central line associated blood stream infections (CLABSIs) initiative in Pennsylvania. This has been a three year patient safety in-service training initiative supported by The Agency for Healthcare Research & Quality (AHRQ) to reduce central line associated blood stream infection in intensive care units. The analysts are currently working with JHU to provide a control group from Pennsylvania for further validation of CUSP. This would be the first time CUSP was measured against non-CUSP units from an infection rate point of view. Traditionally CUSP has used unit specific historical controls. According to HAP the plan also is to have as many cohort II and IV units enroll in HEN as possible. Authority IC analysts are serving as consultants for all HAP controlled HAI work and project plans.

Statewide Preventing Wrong Site Surgery Project

The Pennsylvania Patient Safety Authority (Authority) will collaborate with Pennsylvania hospitals to prevent wrong-site surgery (WSS) through the implementation of standardized procedures and evidence-based best practices. The Authority will develop and implement a strategic and cohesive program that provides education, tools, technical assistance, resources, and an interactive forum to facilitate hospitals’ efforts to prevent wrong-site surgery. See “Scope of Project” for further details. 

The scope of the Wrong-Site Surgery Prevention Collaboration is as follows:

  • Creation of a collaborative learning network for the prevention of WSS.
  • Collection of baseline data using facility-level surveys and direct observation of operations.
  • Education for designated surgical teams using medical literature, the Authority’s database information, and other pertinent educational resources regarding wrong-site surgery prevention.
  • Dedication of a shared website to document all activities in this endeavor.
  • Guidance, assistance, and technical support for all participating hospitals.
  • Collection of follow-up data and the development of comparison reports to measure progress at the end of the program.

The Authority will gather baseline assessment and compliance monitoring data. Each participating hospital will complete and submit the following information which will be collected and analyzed by the Authority:

  • “Self-Assessment Checklist for Program Elements Associated with Preventing Wrong-Site Surgery.”
     --Survey for facility adoption of WSS preventive practices
     --“Wrong-Site Surgery Prevention Observational Monitoring Tool”
     --Forms for operating room observation in which each hospital conducts direct observations of 10 surgical procedures to monitor compliance with WSS prevention protocols.

After approximately six months, each participating hospital will re-take the Self-Assessment Checklist for Program Elements Associated with Preventing Wrong-Site Surgery and directly observe another 10 surgical procedures to monitor compliance with WSS prevention protocols using the Wrong-Site Surgery Prevention Observational Monitoring Tool for comparison reports. Results will be submitted to the Authority for analysis and de-identification before sharing with the participating hospitals.

The outcome measure will be the number of wrong-site surgeries from each participating facility as identified from reported events through PSRS during the collaboration period. The number of wrong-site surgeries will be reported to each participating hospital quarterly.

Statewide Falls Collaborative Project

1.  Evaluation of the Falls Reduction and Prevention Project will occur thru tracking of aggregate and individual falls and falls with harm rates over time. Additionally, data collected will assist hospitals in identifying patient activities and strategies that can result in the greatest impact on reducing falls for participating hospitals, compared to concurrent and historical controls.

2. Falls Program Assessment 

There will be two process measures for this project. Participating hospitals will submit falls related data to the Authority reporting system to establish trends in the activities associated with falls and prevention strategies used when falls occur.

These two process measures will provide the percentage of falls, both incident and serious event, by:
1. Falls prevention strategies and
2. Falls details.

The prevention strategies selected were based on the Authority’s southeast region falls initiative and the literature. There will be an option for participating hospitals to identify additional fall prevention strategies. The Authority will continue to use the falls details currently in the PA-PSRS database with the addition of three new variables identified from the literature.

There will be six outcome measures that will delineate between inpatient and outpatient falls rates. The six outcome measures are:

  • Falls per 1,000 patient days (inpatient falls rates)
  • Falls with harm per 1,000 patient days (inpatient falls rates)
  • Falls per 1,000 patient encounters (outpatient falls rates)
  • Falls with harm per 1,000 patient encounters (outpatient falls rates)
  • Falls per 1,000 adjusted patient days (a facility-level falls rate that combines inpatient and outpatient rates)
  • Falls with harm per 1,000 adjusted patient days (a facility level falls rate that combines inpatient and outpatient rates)

Collaborative Progress:

  • The project team and some volunteer facilities are currently testing the changes to the falls data collection portion of PA-PSRS
  • We have developed the updated PA-PSRS user manual and program memorandum which will be sent to facilities.
  • We have begun development of the specification for the Falls Reports from PA-PSRS
  • We are reviewing literature and toolkits available on falls prevention
  • We are preparing for the statewide PA-PSRS webinar on falls
  • We are developing a project training schedule and enhancement to the project timeline.


As part of a proposal with HAP, QIP and HCIF, to CMS for their Partnership for Patients campaign, the collaborative to address the safe use of opioids has been accepted as a part of the overall proposal. The goal of this collaborative would be to decrease in the number of harmful events with opioids, by quarter for participating hospitals, compared to the participating organizations’ baseline (concurrent and historical controls).

To assist organizations with reducing the risk of patient harm from the use of opioids throughout their organization, this project would explore the current trends in opioid therapy within organizations, barriers to optimal therapy and safety, common types of errors that occur with opioids and contributing factors that lead to patient harm from opioid use. This project would involve any care or procedural area where opioids are used as well as practitioners who would prescribe, dispense, administer and monitor patients on opioids.

There will be two assessments conducted as a part of this collaborative. The Authority, in conjunction with the PA Medical Society, has developed a clinician knowledge assessment tool for opioids which will be accessible to physicians, pharmacists, and nurses. The results of the knowledge self-assessment would be used to identify gaps in clinicians’ knowledge with respect to opioids.

We are in the process of developing an organizational assessment that hospitals can use to evaluate their current practices around opioid use. The organizational self-assessment is designed to help hospitals identify weaknesses in their medication use processes with the use of opioids to create their action plans.

Outcome measures would be documented on PSA developed measures worksheets and then entered into Ancilla. The outcome measures would include:

1) Measuring the use of naloxone (Narcan®) [an opioid reversal agent], for example, comparing the number of patients receiving IV opioids and how many of those patients needed to have the adverse effects from the opioids reversed with naloxone;

2) Measuring the number of patients receiving IV opioids who needed to be resuscitated by rapid response teams.

Analysis of reports submitted through the Pennsylvania Patient Safety Reporting System to determine to what extent preventable adverse outcomes related to the use of opioids have declined. Focus may be on determining to what extent the adverse outcomes occurred in hospitals participating in the project versus those that occurred in non-participating project hospitals.

Patient Safety Education for all HEN Hospitals Project

As part of the Pennsylvania HEC program, all participating organizations will be expected to voluntarily participate in core set of competencies that recognize a culture of safety as the primary mechanism to improve outcomes and reduce harm. As it is developed, the Culture of Safety Core Curriculum can serve to enhance knowledge of safety-related concepts and convey patient safety philosophy, principles and strategies to ensure the best chance of success in reducing harm. Organizations may be expected to complete a baseline Culture of Safety Survey in order to determine hospital specific areas for improving patient safety and outcomes.
As another aspect of general education, all hospitals will need to be educated on the risks associated with errors and the potential for reducing those risks within their own organizations. In order to determine these elements of risk, hospital participants will be provided education on the difference between proactive and reactive risk assessment and reporting requirements. Participants will have the opportunity to learn strategies for increasing awareness of patient safety and risk assessment and responding to the need for disclosure when events do occur.

  • Faculty from the Patient Safety Authority’s Liaison Program will provide the following as part of the core safety curriculum:
    Integrating Safety Into Work Practices / Organizational Patient Safety
  • Teamwork
  • Human Factors
  • Communication
  • Patient Engagement
  • Strategies to Increase Awareness of Patient Safety and Risk Assessment
    Through an initial face-to-face conference, participating hospitals will cover these core aspects of the culture of safety in a one day session. Additionally, hospital participants will receive ongoing and integrated culture of safety education and training throughout topic specific presentations and sessions using concepts including but not limited to TeamSTEPPS, CUSP, Just Culture and principles of Lean.

    A Patient Safety Educational Curriculum has been developed for the HEN and  is currently is being reviewed. In a recent survey conducted by HAP of the HEN facilities, about 700 individuals are slated to be educated. We have divided the state regionally and will begin this educational offering the last week of March in the south central region.  Venues are being secured and hold the date notifications will be sent. Printing will be underway as soon as the review process in completed. Due to federal contracting rules we are not permitted to serve food to the 700 attendees.  This is a significant issue in the selection of a venue since the program is six and a half hour educational session.

    We are also developing “Just in Time Learning” segments which will be posted on PassKey for each facility to choose as their needs dictate. These will be one hour sessions much like a recorded webinar.  These topics are:



2012 -2013

Just in time self-learning

1.        Available in PassKey

2.        Webinar platform

3.        Presenters: Megan Shetterly, Fran Charney and Chris Hunt

4.        Duration: one hour / topic

5.        Facility on demand through PassKey

6.        Posted in June 2012




Project Titles:

  • PassKey introduction for HEN users
  • Just Culture

·         Human Factors

·         Root Cause Analysis

·         Failure Mode Effects Analysis

·         Process Mapping

·         Patient Safety Takes a Team

·         Situational Awareness

·         Communication

·         Teamwork

·         Leadership

·         Why reporting Matters





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