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Patient Safety Authority Annual Report Highlights Progress in Patient Safety

Pennsylvania’s Patient Safety Authority (PSA) has released its 2019 Annual Report. The report highlights activities of the PSA, including its September 2019-launched quarterly peer-reviewed journal, Patient Safety. It also includes an analysis of patient safety events reported into the Pennsylvania patient safety reporting system (PA-PSRS), a secure database that collects health care facility data on “serious events” and “incidents.”

In both 2018 and 2019, 97 percent of reports were defined as “incidents” and three percent were “serious events.” Reporting rates have increased significantly in recent years and, in 2019, were up 26 percent from 2015 reporting levels. Across acute care settings, the most common event in each of the last five years were “errors related to procedure/treatment/test” (33% of all acute care event reports). Other events in 2019 included medication errors (18%), complication of procedure/treatment/tests (16%), and falls (11%). PSA researchers and analysts note that “the increase in reporting rates each year may reflect improvements in patient safety culture across the Commonwealth….”

The report identifies areas of harm that health care providers should take to minimize events (e.g. telemetry monitoring, infant falls, and IV pump issues).

The PSA, created during 2002 with HAP’s support, promotes patient safety by analyzing data and making recommendations about steps that providers can take to prevent similar events from happening in the future.

The PSA has been part of the HAP Hospital Improvement Innovation Network (HIIN) and led key topics including: health literacy, diagnostic errors, falls, culture of safety, and adverse drug events. HAP thanks the PSA for remaining partners in this important work.  

For more information about the report, contact Sari Siegel, HAP’s vice president, healthcare research. For more information about HAP’s HIIN, contact Rob Shipp, vice president, quality and population health.


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