PA -PA
PSRS
- PSRS
Pennsylvania
Patient Safety Reporting System
Alan B.K. Rabinowitz
Administrator, Patient Safety Authority
2006 National Health Policy Conference
February 7, 2006
PA - PSRS
Objectives
• Background on Pennsylvania’s
mandatory reporting statute
• The PA-PSRS System
• Sharing Data
• Lessons Learned
• Assessment after 18 months
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PA - PSRS
Pennsylvania: Background for State Action
• Escalating Medical Malpractice Insurance
Premiums
• Alleged Physician Exodus
• Threatened Closure of Hospital-based Clinical
Services
• IOM Report (1999): “To Err Is Human”
• Public Expectations
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PA - PSRS
Slide courtesy of:
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PA - PSRS
From Mark Twain 1864
“It would be a good thing for the world at large, however
unprofessional it might be, if medical men were required
by law to write out in full the ingredients named in their
prescriptions. Let them adhere to the Latin, or Fejee, if they
choose, but discard abbreviations, and form their letters
as if they had been to school one day in their lives, so as
to avoid the possibility of mistakes on that account.”
Mark Twain
San Francisco Morning Call
October 1, 1864
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PA - PSRS
Act 13: Medical Care Availability and Reduction of
Error Act of 2002
• To reduce and eliminate medical errors by identifying
problems and implementing solutions that promote
patient safety
• Establishes the Patient Safety Authority
• Promulgates facility-based reporting requirements
• Mandates written patient notification and designation
of patient safety officers, plans and committees
• Administrative provisions, including patient safety
CME requirements and self-reporting
• Medical malpractice-related and tort reform
provisions
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PA - PSRS
PA Patient Safety Authority
• Independent agency under an 11-member Board
• Non-regulatory
• Dedicated funding stream outside of the General Fund
• Collects, analyzes and evaluates trends of serious events
and incidents
• Makes recommendations for improvements in healthcare
practices
• Advises facilities on matters related to patient safety
• Issues an Annual Report
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PA - PSRS
PA - Reporting Components
Who Reports
Acute Care Hospitals
Ambulatory Surgical
Facilities
Birthing Centers
Types of Events
Near-Misses
(“Incidents”)
Adverse Events
(“Serious Events”)
[Infrastructure Failures]
-----Incidents and Serious
Events to PSA
Serious Events and IFs
to DOH
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Other
Considerations
Mandatory
No Individual
Identifying Data
Confidentiality
Provisions
Non-discoverable
Whistleblower
Protections
Facility assessment
PA - PSRS
Report Intake
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Anonymous Reports of Serious Events
• Only applies to Serious Events
• Must be submitted by a healthcare worker
• Event must first be reported through facility’s
reporting process
• Verification and possible review by Authority
• Referral to Department of Health for failure to
report
• Whistleblower protection
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Roadblocks
• Complex IT project
• Pennsylvania’s population distribution
• 420 facilities
• Legislative expectations and media scrutiny
• Time Sensitivity
• Perceived “Solution” to Med/Mal crisis
• Public confusion between learning and
accountability
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System Development
• Five-year $10.5 million contract
• Data collection and analysis
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System Design
• Web-based
• Based on UHC Patient Safety Net
• User-friendly
• Real-time feedback
• Internal analytical tools
• Data export capacity
• Interface development
• No additional user costs
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PA - PSRS
Pennsylvania Patient Safety Reporting
System (PA-PSRS)
Report Intake:
• 21 Core Questions
– Patient Age / Gender
– Location
– Event type
– Level of harm, contributing factors and root causes
– Several narrative fields
– Recommendation to prevent future occurrence
• Additional Event Detail Questions
– 15 Major categories, 233 sub categories
• 250 Specific Event Types
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PA-PSRS: Clinical Analysis
Incoming
Reports
Triage
Patient Safety
Review Meeting
Analytics
Program
Outputs
PSA Annual
Report
Public Advisories and
Recommendations
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Contact with
Individual
Facilities
PA - PSRS
PA-PSRS
Report Output:
• Real time feedback to facilities
• Patient Safety Advisories
• Annual Report
Related Activities:
• Education and Outreach
• Research
• Promotion of Culture of Safety and Full and
Open Disclosure
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Recent Advisory Topics
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Use of Color-Coded Wristbands
Creates Unnecessary Risk
(Supplementary)
Unanticipated Care after Discharge
from ASF’s
The Beers Criteria: Medication
Screening in the Elderly
Hidden sources of Latex in
Healthcare Products
Use of X-Rays for Incorrect Needle
Counts
Patient Identification Issues
Falls Associated with Wheelchairs
Medication Errors Linked to Name
Confusion
When Patients SpeakCollaboration in Patient Safety
Anesthesia Awareness
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•
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Dangerous Abbreviations in
Surgery
Problems Related to Informed
Consent
Focus on High Alert Medications
Bed Exit Alarms to Reduce Falls
Confusion between Insulin and
Tuberculin Syringes
(Supplementary)
The Role of Empowerment in
Patient Safety
Risk of Unnecessary Gallbladder
Surgery
Changing Catheters Over a Wire
(Supplementary)
Abbreviations: A Shortcut to
Medication Errors
Lost Surgical Specimens
PA - PSRS
Annual Report for 2004 (Issued May 2005)
• 70,000 Reports in 6 Months
• 95% Reports = Events without harm
• 35% of Facilities Implemented New Procedures in
Response to PA-PSRS
• Falls and Medication Errors = Largest Number of
Reports
• Procedure Complications = Largest Number of
Reports with Harm
• 59% of Events with Harm Involve Elderly
(cf: 41% of Inpatient Hospitalization = Elderly)
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PA - PSRS
Statistics
Event Type
PA-PSRS
Medication Error
25%
Adverse Drug Reaction
2%
Equipment/Supplies/Devices
2%
Falls
21%
Error Related to Procedure / Treatment / Test
19%
Transfusion
1%
Complication of Procedure / Treatment / Test
15%
Skin Integrity
8%
Other / Miscellaneous
7%
PA-PSRS n = 243,474
(as of2001/07/06)
PA - PSRS
Patient Safety Lessons
•
Patient Identification
•
High Alert Medications
•
Drugs Associated with Falls
•
Informed Consent is No Excuse
•
Syringe Confusion
•
Unlabeled Bowls in Surgery
•
Abbreviations
•
Errors Related to IT
•
Hospital Acquired Infections
•
Wristband Confusion
•
Stress Management
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Supplementary Advisory
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PA - PSRS
Colors Used in Wristbands (Dec 2005 Survey)
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PA - PSRS
PSA: Assessment
Mandatory reporting vs. conventional wisdom
• Volume indicates good “buy in”
• Help-Desk queries and facility feedback = user satisfaction
Value of near-miss reporting
• Encourages communication and empowerment
• Application of Patient Safety Advisories / shared learning
• Promotes internal QI and patient safety initiatives
Everything You Need to Know You Learned from Your
Grandmother
Logistics
• Adequate funding
• Aesop’s Fable: The Tortoise and the Hare
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PA - PSRS
PA-PSRS: Ongoing Goals
Promote Education and Training
• Root Cause Analysis: Targeted to Patient Safety Officers
• Patient Safety Concepts: Culture of safety, legal principles,
best practices, national initiatives: Targeted to executives,
CMOs and physician champions
• Promote Culture Change: Targeted to Trustees
Encourage Research
• Develop Protocols Governing Access to Data
Facilitate Data Sharing
• Partner with other Data Collection and Research Entities
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Comments About PA-PSRS
“I think we’re going to see in the Pennsylvania model a way to use mandatory
reporting in a positive way that will make a difference.”
Lucian Leape, MD
Harvard University
“Pennsylvania [has implemented] new patient safety initiatives that are seen
as among the most progressive in the nation.”
Philadelphia Inquirer
June 1, 2004
Recipient of 2004 Healthcare IT Innovator Award from Healthcare Informatics
magazine (September 2004 issue)
Published by McGraw-Hill Companies
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PA - PSRS
Comments About PA-PSRS
“Pennsylvania’s health care providers and patients are fortunate to have
their safeguards championed by the Patient Safety Authority....By
implementing the Pennsylvania Patient Safety Reporting System, the
Authority has begun to assist health care systems in successfully
identifying and correcting their shortcomings....Patients and health care
providers are benefiting from the efforts of this pioneering group.”
William W. Lander, MD
Past President
Pennsylvania Medical Society
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PA - PSRS
Culture of Safety
The ultimate success of the PA-PSRS
system is not in the number of reports we
receive, but in how facilities and individual
providers use the information within those
reports to improve patient care.
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PA - PSRS
PA Patient Safety Authority
www.psa.state.pa.us
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