Pennsylvania Patient Safety Authority Issues Annual Report for 2013 - KCTV5

Pennsylvania Patient Safety Authority Issues Annual Report for 2013

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SOURCE Pennsylvania Patient Safety Authority

The report shows decreases in Serious Event reports, wrong-site surgeries, falls and healthcare-associated infections

HARRISBURG, Pa., April 30, 2014 /PRNewswire-USNewswire/ -- The Pennsylvania Patient Safety Authority issued its 2013 Annual Report showing decreases in Serious Event reports in hospitals and ambulatory surgery facilities (ASFs) over the last five years, wrong-site surgeries (WSS), falls and healthcare-associated infections (HAIs). 

"This June will mark 10 years since the Authority began collecting data from Pennsylvania's hospitals and ASFs," Carrie DeLone, M.D., chair of the Pennsylvania Patient Safety Authority board of directors said. "While it's difficult to specifically gauge how much patient safety has improved in Pennsylvania, the Authority has seen some success within individual healthcare facilities working in collaborations and an overall decrease in Serious Event reports.

"While Serious Event reports have decreased, Incident or near miss reports have increased in the last five years which may show how facilities view reporting as a means of preventing more harmful events, " DeLone added. 

DeLone said the Authority continued its collaborative efforts, some as part of the Centers for Medicaid and Medicare Services (CMS) Hospital Engagement Network's (HEN) Partnership for Patients (PfP) campaign. The PfP campaign focuses on reducing healthcare-acquired conditions with goals to keep patients from getting injured or sicker and to help patients heal without complication.  

"Through the PfP campaign, the Authority has continued to work with about 130 Pennsylvania hospitals and the Hospital and HealthSystem Association of Pennsylvania to prevent wrong-site surgeries, falls and high harm medication errors," DeLone said.

"There have been decreases in harmful events for each project which will continue through December of this year," DeLone added.

Overall, wrong-site surgery procedures have trended down 3.4% per year in reference to the overall yearly average, DeLone said. Pennsylvania facilities reported 10 wrong-site surgery procedures July through September 2013, which is the lowest number of wrong-site surgery procedures reported for the first quarter of any academic year since event reporting began through the Pennsylvania Patient Safety Reporting System (PA-PSRS).

DeLone added that facilities participating in the project received onsite visits conducted by the Authority's WSS team. Onsite observations showed a 19% average improvement for five process measures that monitored surgeon verification of the site mark with various documents, including: 1) patient's or surrogate's understanding of the procedure; 2) consent; 3) schedule; 4) history and physical examination; and 5) pathology reports, radiology reports and/or radiographs, as applicable.

The HEN falls data for December 2013 has shown an aggregate reduction of 54% in unit level falls with harm and a 45% reduction in facility level falls with harm from the project's baseline. DeLone added that the falls project has had up to six months of greater than 40% reduction in falls with harm. There are eight hospitals in the project that have had 16 months of zero falls with harm and many other hospitals are seeing sustainable results.

DeLone said along with the PA-HEN collaborations the Authority worked with ASFs to reduce day-of-surgery cancellations and unscheduled transfers to hospitals.  In June 2013 the Authority also published results of a two-year study of 10 nursing homes with high HAI rates and their efforts to implement best practices to prevent infections. The analysis of the study showed a 16% decrease in the mean overall infection rate for the 10 participating nursing homes with high infection rates.

For more information on the Authority's collaborations, go to Addendum G in the 2013 Annual Report at To view more results of the infection study in the Patient Safety Advisory or overall infection rates in Pennsylvania, go to Addendums C and H respectively.

DeLone said the Annual Report also highlights the Patient Safety Liaison (PSL) program.

"Since 2010, the education programs provided by the Authority have increased by sixty-seven percent," DeLone said. "The audience attending the programs has also grown to include not just patient safety officers but other disciplines such as quality directors, front line staff and executive leaders."

DeLone said the largest volume of education sessions are for facility-specific education with programs offered based upon individual facility requests and/or identified needs.

"The PSL program's success lies in the liaisons' ability to meet with Pennsylvania hospitals and ASFs that report through the MCare Act to help them determine what educational resources they need to improve patient safety within their facilities," DeLone added. "Pennsylvania is ahead of the curve in having a program that is able to respond to facilities' individual educational needs."

DeLone said the Authority's PSL program has provided education sessions to Pennsylvania healthcare workers on topics such as the importance and value in event reporting, culture, human factors, teamwork and communication, infection prevention, wrong-site surgery prevention, falls prevention, medication safety, fire safety in the operating room, disclosure and others.

For more detailed information on the Authority's PSL program and education sessions, go to Addendum D in the 2013 Annual Report at

DeLone said the Authority's campaign to recognize Pennsylvania healthcare workers' patient safety efforts is also highlighted in the 2013 Annual Report.

The "I Am Patient Safety" poster contest highlights individuals and groups within Pennsylvania healthcare facilities who have made a personal commitment to patient safety. The contest is held annually with winners announced in the March Pennsylvania Patient Safety Advisory.

Submissions for the poster contest were judged upon the following criteria: The person or group 1) had a discernible impact on patient safety for one or more patients, 2) demonstrated a personal commitment to patient safety, and 3) demonstrated that a strong patient safety culture is present in the facility. Bonus points were awarded for submissions that demonstrated initiative taken by an individual.

"The healthcare workers featured on the posters range from doctors to administrative and housekeeping personnel," DeLone said. "The poster recognizing these efforts shows how important it is for everyone who works within the healthcare facility to make the personal commitment and help keep patients safe no matter what your line of work."   

For more information about the Authority's poster campaign to recognize patient safety efforts go to Addendum H of the 2013 Annual Report at  

The complete Annual Report for 2013, as well as additional information about the Patient Safety Authority, is accessible on the Authority's website

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