Patient Safety Authority Logo

Skip navigation links
HOME
PATIENT SAFETY AUTHORITYExpand PATIENT SAFETY AUTHORITY
PA-PSRS and PASSKEYExpand PA-PSRS and PASSKEY
PATIENT SAFETY ADVISORIESExpand PATIENT SAFETY ADVISORIES
PATIENTS AND CONSUMERSExpand PATIENTS AND CONSUMERS
NEWS AND INFORMATIONExpand NEWS AND INFORMATION
EDUCATIONAL TOOLSExpand EDUCATIONAL TOOLS
AUTHORITY EVENTSExpand AUTHORITY EVENTS







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


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


  
Advisory Banner
Patient Safety Authority Update
PA PSRS Patient Saf Advis 2005 Jun;2(2):1-2.    
 

This month marks the one year anniversary of the PA-PSRS system, a significant milestone in patient safety for Pennsylvania’s healthcare providers and patients alike.

While we will have received more than 150,000 reports by the time this Advisory goes to print, numbers alone are not the measure of PA-PSRS’s success. That measure is the result of how facilities use PA-PSRS and how they respond to Act 13’s other patient safety requirements.

In a recent conversation, the vice president for medical affairs at a hospital in Central Pennsylvania spoke enthusiastically about how Act 13 and the PA-PSRS reporting system raised patient safety to the forefront within his facility.  He described how they considered patient safety in designing a new wing and how mandatory reporting has enhanced communications between different segments of the staff. PA-PSRS, he recounted, has increased physician awareness of process issues and is encouraging nurses to speak out more freely. In summary, he concluded that PA-PSRS has both focused his organization’s attention on patient safety and actually increased patient safety within his facility.

These are not isolated comments. In a recent news story carried in publications targeted to the physician community, several hospital executives cited examples where PA-PSRS has facilitated clinical improvements and other positive outcomes within their organizations. For example, a critical access hospital streamlined its patient transfer process based on the results of a root cause analysis conducted after a PA-PSRS report submission. A large academic medical center reported making changes within its operating rooms as a result of a recent Patient Safety Advisory article. And a community hospital attributed a reduction in medication errors to use of the PA-PSRS analytical tools, singling out the usefulness of being required to answer questions related to so-called “contributing factors” on the PA-PSRS reporting form.

While each of the above-cited facilities focuses on different aspects of PA-PSRS, their examples validate the system’s usefulness and the benefits of a mandatory reporting system based on a culture of learning. This issue of the Patient Safety Advisory, the eighth since we initiated publication last year, is an integral component of the Authority’s commitment to promote patient safety by sharing knowledge and best practices. As one hospital executive noted, Advisory articles are inherently practical because they are derived from actual events in Pennsylvania institutions, whereas many academic articles about patient safety have little immediate clinical relevance.

We hope that you are finding PA-PSRS beneficial in enhancing patient safety efforts and promoting a culture of safety within your facility. We encourage you to share your experiences with us so we, in turn, can share them with others.

Alan B. K. Rabinowitz
Administrator
Patient Safety Authority

 
 Browse by Topic
go button Discipline
go button Audience
go button Care Setting
go button Event
go button Patient Safety Focus
go button Hospital-Acquired Condition
Print Page Print / Save PDF
Email to a Friend Email to a Friend
Editorial Information Editorial Information
Subscribe to Advisory Subscribe to the Advisories
Navigation  
Back to Advisory Issue

Article Sections
Patient Safety Authority Update



THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO 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 LOGO 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.      

ISMP Logo 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.      
 
©2012 Pennsylvania Patient Safety Authority                                                Home      Who We Are      Contact Us     Subscribe to Advisories and Press Releases   Site Map     Privacy Statement