This issue of the Patient Safety Advisory marks three full years of publication. Since releasing the first quarterly issue in March 2004, the Authority has published 12 quarterly and 4 Supplementary Advisories, containing more than 100 individual articles based on actual adverse events and near-misses reported through the PA-PSRS system.

The Advisory has grown in quality with each successive issue, and Dr. John Clarke, PA-PSRS clinical director and Advisory editor, can be justifiably proud of the final product and the research conducted by the team of PA-PSRS clinical analysts.

But the measure of the Advisory’s success is in whether, and how much, it generates discussion, promotes change and improves patient outcomes in Pennsylvania’s healthcare facilities. That’s been our ongoing mantra over the past three years: translating the clinical guidance included in each Advisory article into actionable programs to improve patient care.

Since PA-PSRS was implemented, I’ve observed that many, if not most, submitted reports involve uncomplicated situations. These reports are not the result of sophisticated, complex or high-tech activities but simple systems failures such as problems associated with hygiene, communication, hand-offs, patient identity or procedure verification. Many events involve a problem that has long been identified and whose solutions are well known. Many relate to National Patient Safety Goals or are included on the list of the National Quality Forum’s “never events.” Unfortunately, systems are not yet in place throughout the industry to prevent repeated occurrences of even these commonly recognized problems.

Take, for example, reports of wrong medication, wrong dose, or administration to the wrong patient. A recent report from the Institute of Medicine, Preventing Medication Errors, estimated that a startling 1.5 million Americans are injured annually by medication errors.¹ Not surprisingly, one of the report’s most basic recommendations was the computerization of prescription order systems.

This is not a new concept, yet it is commonly acknowledged that healthcare providers have been slow to adopt electronic medication systems. Even so, I was taken aback by a story in my small-town newspaper that demonstrated just how slow the health industry has been.

In a news article about the annual Shippensburg Community Fair, an oldfashioned eight-day event in rural Cumberland County, the reporter described the baked goods competition, where judges consider a multitude of factors (i.e., flavor, lightness, consistency, texture, crumb and general appearance) for a variety of cakes, cookies and pies submitted by people assigned to several categories (i.e., by age and gender).² The judges have to take these many variables into account in selecting a winner. However, this year, the husband of the baked goods committee chairwoman developed a bar-coded computer system to track submissions, record the scores, and tabulate the results.

While healthcare is obviously a more complex endeavor than a pie contest, we should all ask ourselves if a computer system can be developed and implemented for a pie contest, why wouldn’t we invest in one for something as critical as our healthcare system?

I am not singling out computerized prescription order entry systems as much as I am encouraging the healthcare industry to hasten the implementation of proven protocols and interventions, whether electronic or otherwise, that are known to mitigate patient harm and improve patient outcomes, the kinds of clinical guidance contained in the Patient Safety Advisory.

After three years of publishing the Advisory, we continue to ask how you are utilizing PA-PSRS resources, whether Advisory articles or embedded analytical tools, to improve patient care in your organization. And we continue to invite you to submit accounts of your experiences. That is, after all, the point of PA-PSRS. As we have often said, we want to share the lessons you have learned and best practices you have adopted so other providers and managers can benefit from your patient safety success stories.

In closing, let me note that this is my final column for this publication. In mid-November, I submitted my resignation to the Board, effective at the end of the year. Looking back over the past four years, I value the opportunity to have worked with you, in many cases personally. This agency’s success and the national recognition we have earned is due in large measure to the commitment of Pennsylvania’s healthcare community to improving patient safety and engaging in a common vision of quality improvement. I will follow your progress with keen interest.

Notes

1. Aspden P, Corrigan JM, Bootman JL, et al. Preventing medication errors. Washington (DC): National Academies Press; 2006.
2. Gates O. Baked-good judges have a sweet time. The Sentinel 2006 Jul 9.

Alan B.K. Rabinowitz
Administrator
Patient Safety Authority