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333 Market Street
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Harrisburg, PA 17120

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Patient Safety Authority Update

PA PSRS Patient Saf Advis 2004 Dec;1(4):1.

It has been five years since the release of the Institute of Medicine’s seminal report To Err Is Human, and there has been considerable discussion among both health policy makers and the media on the report’s impact. In response to the question, “Is healthcare any safer today than it was five years ago?”, an honest answer would be, “Yes, but there is a lot more to do.”

Certainly, the development and implementation of the PA-PSRS system is, in great measure, a direct outcome of the groundbreaking IOM report. In the six months since the start of statewide mandatory reporting, we have received more than 60,000 reports of Serious Events and Incidents. This is a significant database that allows individual facilities and PA-PSRS analysts to assess the types of adverse events and near misses that are occurring, identify why they occurred, and suggest steps they can take to prevent reoccurrence.

A distinguishing characteristic of the PA-PSRS system, one that sets it apart from other adverse event reporting systems around the country, is that PA-PSRS contains integral analytical components that provide immediate feedback to facilities. These analytical tools, as well as Patient Safety Advisories based on specific reports submitted through PA-PSRS, will be a measure of the system’s success as we move forward. Correspondence from facilities indicates considerable use of the analytical tools. We are told that Advisory articles are widely distributed to clinical and program staff. And we are encouraged to hear “success” stories detailing changes made by individual facilities as a result of the lessons learned through the PA-PSRS system.

As PA-PSRS staff have repeatedly counseled, the success of this program is not in the number of reports the system collects, but in what individual facilities do to enhance their internal quality improvement and patient safety efforts. So, five years after the IOM report and six months after the start of PA-PSRS, how is your facility responding to the issue of patient safety?

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Patient Safety Authority Update

	THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS
	The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .
	ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.
	The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.