HARRISBURG: All Pennsylvania-licensed hospitals, ambulatory surgical facilities and birthing centers are now reporting through the new Pennsylvania Patient Safety Reporting System (PA-PSRS).

The Patient Safety Authority developed PA-PSRS (pronounced “PAY-sirs”) in response to Act 13 of 2002, which charged the Authority with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Pennsylvania is the first state in the country to require the reporting of both actual events and “near-misses.”

More than 400 healthcare facilities are subject to Act 13 reporting requirements. All information submitted through PA-PSRS is confidential, and no information about individual facilities or providers will be made public.

The PA-PSRS program will receive and tabulate reports and analyze data to identify trends and suggest improvements to enhance patient safety. The Authority will make available to the public aggregate data related to both certain geographic regions and the state as a whole, but will not release facility-specific data. An important component of PA-PSRS is a software program that will allow facilities to generate reports specific to their individual facility. Facility managers can use these reports for their internal quality improvement and patient safety activities.

Prior to the start of mandatory reporting, the Authority conducted 19 training sessions in eleven locations throughout the state. Almost all facilities subject to Act 13 reporting requirements participated in these daylong demonstration and hands-on training sessions.

“PA-PSRS program staff worked aggressively over the past several months to ensure that the implementation of PA-PSRS went as smoothly as possible,” said Dr. Robert Muscalus, Pennsylvania’s Physician General and chair of the Authority’s board of directors. “We initiated mandatory reporting in three steps to assure ample time to train facilities on the use of the system prior to the start of mandatory reporting. We are pleased with how well this has gone.”

Mandatory reporting was initiated among facilities in eastern counties on June 7, among facilities in western counties on June 21, and among facilities in counties comprising the central region of the state beginning today.

“For many facilities, this is the first time they have access to an electronic system to track events in their facility,” Muscalus said. “Many personally thanked us for bringing a tracking system into their facility. Others commended us for the comprehensiveness of PA-PSRS.”

In submitting reports, a facility must answer a variety of questions about the circumstances surrounding an event, including the level of actual or potential harm to the patient as well as such factors as staffing or equipment problems that may have contributed to the occurrence. The result is a detailed database that will allow the Authority to identify trends among facilities and recommend improvements that individual facilities may adopt.

"I think the most promising aspects of the PA-PSRS program are the analytical features that allow us to focus on events occurring in specific care areas and enable us to get a better view of the overall picture in our facility by comparing ourselves through aggregate statewide data,” said Dr. Douglas Megill, Patient Safety Officer, Warren General Hospital. “Such an improved picture should help us provide better health care for our patients."

Many facilities expressed similar views about the quality and usefulness of the PA-PSRS system. In response to an anonymous survey of facilities trained on PA-PSRS, comments ranged from “Very nice system. Easy to use with lots of helpful hints. Love the analytical data tools” and “Thanks for your tremendous effort in improving patient safety” to “I think this is the first time a program has been put together with enough input, discussion and understanding of needs.”

Muscalus added that the enthusiasm from facilities for reporting and analyzing events will make the true difference in improving safety in their facilities.

“I’ve said time and time again in training sessions and during other presentations that the ultimate success of this reporting system will not be found solely in the data collected,” Muscalus said. “Rather, improved patient safety will be the result of actions taken by individual facilities in response to what they learn through PA-PSRS.”

The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. The Authority operates under an 11-member Board. Under the Act, all Pennsylvania-licensed hospitals, birthing centers and ambulatory surgical facilities are required to report what the Act defines as “serious events” and “incidents” to the Authority.

In addition, Act 13 also requires that the Department of Health receive certain reports through the PA-PSRS system, including information related to Chapter 51 reporting requirements. Accordingly, the Authority worked closely with that agency to assure that PA-PSRS captured all of their statutory and regulatory reporting requirements. In particular, the Authority expanded the system's capacity to include the submission of "Infrastructure Failure" reports to the Department of Health, even though those reports fall outside the scope of the Authority's responsibility. This assures that facilities have a single portal for the submission of various types of reports and creates a unified reporting tool for the agencies involved.

PA-PSRS is a secure, web-based system developed for the Authority under contract with ECRI, a Pennsylvania-based independent, non-profit health services research agency, in partnership with EDS, a leading international, information technology firm, and the Institute for Safe Medication Practices (ISMP), also a Pennsylvania-based, non-profit health research organization.

For additional information about the Patient Safety Authority or the PA-PSRS program, visit its website at www.patientsafetyauthority.org.

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