HARRISBURG: To mark Patient Safety Awareness Week, Pennsylvania’s Patient Safety Authority is encouraging healthcare facilities and providers to work closely with patients and their families to reduce medical errors by assuring, promoting and improving patient safety.

“Patient safety is everyone’s business,” noted Alan Rabinowitz, Authority Administrator, “and it must be everyone’s priority.”

While injury can result from negligence and even intentionally unsafe acts, the vast majority of events that cause harm are the result of “systems” problems, which can be understood as a series of events involving many people performing different functions in complex healthcare settings. Rabinowitz also added that the potential for error is much greater today than it was a century ago due to the combination of human factors, high-tech electronic equipment and sophisticated, often dangerous, medications and procedures.

According to Dr. Robert Muscalus, Pennsylvania Physician General and chair of the Authority Board of Directors, “We can reduce medical errors by creating a “culture of safety” where people and institutions encourage full and open disclosure to patients, acknowledging mistakes while implementing procedures to prevent future errors.”

Because there are no easy solutions to the issue of medical errors, the Authority emphasizes that everyone involved in healthcare, from hospital trustees and administrators to individual providers like physicians, nurses, pharmacists and technicians, must take an active role in promoting patient safety.

“There’s also a role for individual citizens,” Rabinowitz said. “They are consumers of healthcare, and it’s important for them to become involved by asking questions, staying informed and advocating for themselves and their loved ones.”

Patient Safety Awareness Week is sponsored by the National Patient Safety Foundation as a national education and awareness-building campaign for improving patient safety at the local level. The theme of this year’s commemoration, which is the 4th national observance of the event, is “Ask, Listen & Learn: Effective Communication, the Patient Safety Tool of Choice.”

“We hope that all Pennsylvania hospitals and ambulatory surgical centers, as well other healthcare facilities, will make an extra effort to promote patient safety during this week,” said Muscalus. “While every day should be a safe day for our patients, this is a good opportunity for individual facilities and providers to highlight the important steps they are taking to deliver safer care.”

More information about Patient Safety Awareness Week is available at www.npsf.org.

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 BACKGROUND

 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. More than 420 healthcare facilities are subject to Act 13 reporting requirements.

Facilities submit reports of serious events and incidents through the Pennsylvania Patient Safety Reporting System (PA-PSRS), a confidential web-based system that collects and analyzes data for patient safety and quality improvement purposes. Statewide mandatory reporting through PA-PSRS went into effect in June 2004, making Pennsylvania the first state in the nation to require the reporting of both actual events and “near-misses.”

More than 100,000 reports have been submitted through PA-PSRS since the program was initiated. Based on those reports, the Authority issues quarterly Patient Safety Advisories to advise hospitals and other healthcare facilities about steps they can take to reduce and prevent patient harm. In a recent survey of Pennsylvania’s healthcare facilities, almost one-third of respondents indicated that they have implemented improvements within their facilities as a result of information contained in the Advisories.

Recently, the Authority recommended two programs that healthcare facilities can adopt under Section 312 of the “Mcare” Act, called the Patient Safety Discount section. Facilities may be eligible for a reduction in medical liability insurance premiums if they can demonstrate a reduction in Serious Events as a result of adopting one of these programs. The programs, developed by nationally recognized patient safety organizations, are: “Stand Up for Patient Safety,” developed by the National Patient Safety Foundation (NPSF); and the “100,000 Lives Campaign,” developed by the Institute for Healthcare Improvement (IHI).

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

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