The Pennsylvania Patient Safety Advisory begins its seventh year of conveying educational information from the Pennsylvania Patient Safety Authority’s patient safety reporting system to healthcare providers. Pennsylvania Patient Safety Authority analysts draw from more than one million reports, submitted by Pennsylvania healthcare facilities, for information not available in the literature.

The Authority’s Advisory staff is aided by an editorial advisory board that assists in the peer-review process and provides other valuable feedback. I wish to acknowledge and thank three members whose terms have expired for their service: William Dubin, MD, and Pekka Mooar, MD, both from Temple University, and David W. Orskey, MSHS, formerly from the Hershey Outpatient Surgery Center. I also wish to welcome nine new members to the editorial advisory board: Mary Blanco, RN, MSN; Lawrence M. Borland, MD; Frank M. Ferrara, MD, MBA; Daniel Haimowitz, MD; Mary T. Hofmann, MD; Cheryl Squier, RN, BSN; Donald C. Tyler, MD; Debra Verne, RN, MPA; and Michael R. Weitekamp, MD. Doctors Haimowitz and Hofmann will expand the editorial advisory board’s expertise in the area of nursing homes, and Ms. Squier will also add to the board’s expertise in infections.

How is the Advisory doing? In addition to feedback from the editorial advisory board, feedback was provided by responses from 204 Pennsylvania acute healthcare facilities through the Authority’s 2009 annual survey, plus 364 newly added nursing homes. More than 600 changes have been reported by Pennsylvania healthcare facilities in response to Advisory articles, and dozens of suggestions were made for new Advisory topics. In response to some comments from the survey, the Authority’s Web site allows for browsing the Advisory articles by topic, key word search, and by issue; the educational Webinars for Pennsylvania healthcare facilities are free.

The Authority’s Advisory staff also benefited from a critique following a two-day visit by Tjerk van der Schaaf, PhD. (See picture.) Dr. van der Schaaf, a world expert in chemical safety and near-miss reporting, developed the Eindhoven Classification Model for System Failure. He was also a member of the Institute of Medicine Committee on Data Standards for Patient Safety that made the recommendations that became the Patient Safety and Quality Improvement Act of 2005, establishing national patient safety organizations in the United States. He visited in late 2009 and provided many useful comments.

  Tjerk van der Schaaf, PhD (back row, sixth from left),
  visits with analysts and editors for the
  Pennsylvania Patient Safety Advisory.

The Authority hopes that healthcare facilities will share their experiences implementing best patient-safety practices, either through the Authority’s imminent Pennsylvania PassKey (Patient Safety Knowledge Exchange) initiative or directly to the Advisory. Together, we can discover not only what works best but also how to make it work reliably.

John R. Clarke, MD
Editor, Pennsylvania Patient Safety Advisory
Clinical Director, Pennsylvania Patient Safety Authority
Professor of Surgery, Drexel University