Since statewide mandatory reporting of adverse events and near-misses was initiated two years ago, we have repeatedly stressed that the purpose of the PA-PSRS system is not merely to submit reports into a bottomless data pit but to use those reports as a learning resource. That’s the rationale behind the publication of the Patient Safety Advisory.

Because individual Advisory articles suggest clinical protocols you can implement to prevent a reoccurrence of a similar event in your facility, it is your responsibility to disseminate this information to both policy makers and frontline providers. After all, real improvement in patient care will not occur unless facilities are willing to take the necessary steps to change routines that may be compromising patient safety.

Nearly 75% of hospitals responding to our last user survey said they have implemented changes as a result of information contained in Advisory articles. This statistic is consistent with other findings that credit Act 13 with enhancing patient safety within Pennsylvania’s healthcare facilities. In fact, at least 80% of healthcare executives surveyed said they believe the culture of safety has improved in their facility since the implementation of Act 13.

Facilities frequently provide feedback about how they respond to individual Advisory articles. Sometimes they write to describe a similar incident or to share the results of a root cause analysis. In other cases they explain protocols they previously implemented to prevent such an event from happening. For example, in response to an article on fires associated with alcohol-based solutions, one facility introduced protocols to catch alcohol runoff in the operating room, while a second hospital eliminated the use of alcohol-based hair products by patients. In response to articles citing the importance, if not the necessity, of “time-out” prior to surgery—which remains a continuing problem despite both JCAHO requirements and common sense—another hospital implemented educational programs specifically targeted to surgeons in order to achieve full buy-in for time-out protocols from its physician community.

Perhaps no article has generated as much interest and feedback as the December 2005 Supplementary Advisory on risks associated with colorcoded wristbands. Within days of publication, we heard from patient safety officers at numerous Pennsylvania hospitals and ambulatory surgical facilities, as well as from government officials, health policy makers, and hospital association executives from other states and countries.

Earlier this year, patient safety managers at Allied Services in Scranton helped facilitate a regional task force to approach this problem head-on. Representatives from numerous hospitals and healthcare facilities in Lackawanna County initiated an ongoing workgroup to develop common policies for the use of color-coded wristbands in their institutions and to outline implementation and education plans. Participation has expanded to include facilities in Monroe, Wyoming, Wayne, Luzerne and Cumberland counties. By reaching consensus, workgroup members are demonstrating a shared vision to promote safe practices for their patients, even among traditionally “competing” institutions. As word of their success spreads, similar workgroups are convening in other counties and regions as well. A forthcoming Patient Safety Advisory will be devoted to this robust, and grassroots, initiative. In the meantime, if you would like more information about the workgroup, you can contact Bonnie Haluska at bhalus@allied-services.org.

Interestingly, the event that generated the original Advisory article on colorcoded wristbands was based on one incident in one hospital. While this demonstrates the value of near-miss reporting, it really demonstrates the value of sharing best practices with one another. As I noted at the outset, that’s the purpose of these Advisories. And that’s why I am again asking you to please share your experiences with us so we, in turn, can share the lessons you have learned with others.

Alan B.K. Rabinowitz
Administrator
Patient Safety Authority