HARRISBURG: In recognition of National Patient Safety Awareness Week, the Patient Safety Authority, through its contractor ECRI, issued its first statewide Advisory to nearly 400 health care facilities as it prepares to implement Phase 2 testing of its mandatory reporting system on March 15.
The Advisory describes situations included among test reports submitted through the Pennsylvania Patient Safety Reporting System (PA-PSRS, pronounced PAY-sirs), a web-based electronic reporting system designed to promote patient safety among Pennsylvania’s hospitals, birthing centers and ambulatory surgical centers. The Advisory alerts facilities to actual or potential problems that occurred in other facilities so they can learn from those experiences to prevent similar situations from occurring in their own facilities. (Advisory Attached)
“It is important to note that although the information used in the advisory originates from test data, it is still very useful,” said Dr. Robert Muscalus, Pennsylvania’s Physician General and chair of the Authority’s board of directors. “The trends we are already seeing during the test phase are consistent with national data. It is important to share this information with healthcare facilities so they can determine the need for changes within their own institutions.”
PA-PSRS is the first system of its kind in the country allowing Pennsylvania to become a role model for other states who are devising their own medical error reporting systems.
“Having analyzed state patient safety reporting systems, I believe Pennsylvania’s approach through PA-PSRS is innovative in including both adverse events and near misses, and in its capacity for analysis,” said Jill Rosenthal, project manager with the National Academy for State Health Policy. “The reporting system should prove to be useful in identifying best practices that have the potential to improve patient safety.”
Phase 1 testing of the PA-PSRS program was initiated in mid-November. Twenty-two health care facilities volunteered to participate in the program, representing large health systems, academic medical centers, community hospitals, ambulatory surgical facilities and rural hospitals. The facilities are located in 19 different counties in all regions of the Commonwealth.
Phase 2 testing begins next week with the same 22 facilities gaining access to new features of the system that will enable them to do more in-depth analysis within their own facility. Phase 2 also requires the facilities to report serious events and infrastructure failures to the Department of Health. Since these reports will be submitted for testing purposes only, they will not fulfill Department of Health requirements for mandatory Chapter 51 incident reporting. Facilities must continue to submit those reports through the Department’s electronic reporting system until further notice.
The Authority will roll out the PA-PSRS to all healthcare facilities later in the spring. Training for the remaining 360 healthcare facilities is scheduled to begin in late April and continue through June with the expectation that all facilities will be reporting to PA-PSRS by early summer.
“The timeline we’ve set for ourselves is ambitious,” Muscalus said. “But at the same time, we know how important it is for us to get this system up and running. It is a work-in-progress, but to date we have had very positive feedback throughout the state, country and at the federal level on PA-PSRS. The system is very comprehensive, yet user-friendly.”
Marge Keyes, a patient safety team leader at the federal Agency for Healthcare Research and Quality, recognized the Patient Safety Authority’s forward thinking.
“Pennsylvania is to be commended for developing and implementing its new patient safety reporting system,” Keyes said. “By following the recommendations outlined in the Institute of Medicine’s 1999 report, Pennsylvania has taken steps that should not only improve patient safety in their state, but result in lessons for other states interested in setting up similar systems.”
One such state interested in setting up its own reporting system is Florida, which has consulted with Muscalus about how PA-PSRS fulfills Pennsylvania requirements to promote patient safety.
Paul Barach, Director of the Miami Center for Patient Safety at the University of Miami, and principal investigator and architect of the Florida Patient Safety Plan has been able to review PA-PSRS.
“Pennsylvania provides Florida with a great role model as we explore how best to advance patient safety and harm prevention,” Barach said. “PA-PSRS is well designed and promises to be an excellent reporting system which will bring much valuable information to Pennsylvania. We will be following its progress closely as we look to develop our own system in Florida.”
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, to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. 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.
The PA-PSRS program will receive and tabulate reports submitted by facilities and analyze that data to identify trends and suggest improvements to enhance patient safety. All information submitted through PA-PSRS is confidential, and no information about individual facilities or providers will be made public.
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. Also under the Act, the Patient Safety Authority must use its contractors (ECRI and ISMP) to directly advise reporting medical facilities of immediate changes that can be instituted to reduce serious events and incidents.
For additional information about the Patient Safety Authority or the PA-PSRS program, visit its website at www.patientsafetyauthority.org.
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*Editor’s Note: Attached are the 22 healthcare facilities participating in Phase 2 of the PA-PSRS project.
PA-PSRS Phase 2 Participants
UPMC Passavant (Pittsburgh, Allegheny County)
Robert Packer Hospital (Sayre, Bradford County)
Reading Hospital & Medical Center (Reading, Berks County)
St. Mary Medical Center (Langhorne, Bucks County)
Gnaden Huetten Memorial Hospital (Lehighton, Carbon County)
Paoli Memorial Hospital (Paoli, Chester County)
Milton S. Hershey Medical Center (Hershey, Dauphin County)
Saint Vincent Health Center (Erie, Erie County)
Lancaster Regional Medical Center (Lancaster, Lancaster County)
Lehigh Valley Hospital (Allentown, Lehigh County)
Geisinger Health System (Danville, Montour County)
Muncy Valley Hospital (Muncy, Lycoming County)
Abington Memorial Hospital (Abington, Montgomery County)
Hospital of the University of Pennsylvania (Philadelphia, Philadelphia County)
Warren General Hospital (Warren, Warren County)
Canonsburg General Hospital (Canonsburg, Washington County)
Wayne Memorial Hospital (Honesdale, Wayne County)
Westmoreland Regional Hospital (Greensburg, Westmoreland County)
Behavioral Health Hospitals
Divine Providence Hospital (Williamsport, Lycoming County)
Ambulatory Surgical Facilities
Exeter Surgery Center (Reading, Berks County)
Ophthalmology Surgery Center (Harrisburg, Dauphin County)
Lebanon Outpatient Surgical Center, LP (Lebanon, Lebanon County)
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