News | April 29, 2008

Pennsylvania Patient Safety Authority Issues 2007 Annual Report

May 1, 2008 - The Pennsylvania Patient Safety Authority today released its 2007 annual report that identifies issues with incident reporting at the state’s hospitals due to confusion over what to report.

The report shows there is substantial variation in the number of reports submitted by different healthcare facilities. While a vast majority of hospitals are reporting serious events (events that cause harm to the patient) and incidents (events that do not cause harm to the patient); the volume varies greatly from facility to facility. The authority said the variation seems to be a lack of consistency in what is reported from hospital to hospital.

Mike Doering, executive director of the Pennsylvania Patient Safety Authority said the authority believes the main reason facilities are reporting inconsistently is because there are differences among them regarding how to interpret language in what is supposed to be reported. He said the authority will work with the Department of Health, which is the state regulator of reporting, to offer facilities more guidance as to what should be reported to bridge the gap in facility reporting levels.

“These differences in reporting by different types of facilities is concerning for several reasons,” Doering said. “If events aren’t reported, we may be missing opportunities to share information that could help to prevent similar events from happening in other facilities.”

He said another concern is when facilities have different interpretations of the serious event definition, a patient who would receive written notification if they were harmed in one facility might not be notified if they were in another facility.

“It is important for open communication to occur between the patient and provider when a serious event occurs so that everyone understands what happened,” Doering said.

When a serious event occurs in a facility the state requires that the patient receives a written notification from the facility explaining what happened. The provision was added in into law to encourage providers to communicate more openly with their patients.

Doering said many facilities have been asking for further guidance about reporting. The authority has provided facilities with program memoranda to help them interpret what should be reported. (e.g. facilities should not consider an event as not reportable simply because it is listed on the patient consent form as a possible occurrence.)

Since these efforts have not proven to substantially decrease reporting variability, Doering said the authority has made standardization a goal for the future.

To accomplish this goal, the authority plans to work with the Department of Health to explore both organizations’ interpretations of the reporting requirements. It will also work with healthcare facilities in the Delaware Valley through the Health Care Improvement Foundation to improve reporting consistency for selected types of events.
The authority plans to perform a comparative analysis of healthcare facilities that are high-and low-volume reporters in an effort to determine what organizational characteristics encourage a greater level of reporting. It will distribute its findings through the Pennsylvania Patient Safety Advisory.

The 2007 annual report also outlines the authority’s strategic plan that aligns its activities more closely with its educational and quality improvement mission. The plan increases the authority’s focus on education and collaboration and identifies several multi-year initiatives, some of which were developed based on feedback from focus groups held with Pennsylvania patient safety officers. Selected initiatives are aimed at educating boards of trustees in their role in promoting patient safety, creating an online forum for more routine sharing of best practices and lessons learned among patient safety officers and creating a patient safety liaison pilot program that will offer healthcare facilities on-site education or quality improvement assistance from the Patient Safety Authority.

Other immediate plans include hiring a director of educational programs, who will direct the authority’s statewide and regional education and training programs and help develop educational materials for facilities to utilize. This person would also supervise the regional patient safety liaisons.

“Many patient safety officers have asked for more of a presence from the Patient Safety Authority to help them implement patient safety initiatives,” Doering said. “We recognize that while every facility shares the same goal to improve patient safety, each facility faces different obstacles in achieving that goal. These new authority employees will work with facilities on a more individual basis to help them achieve their patient safety goals.”

Doering added that several of the initiatives require collaboration with other healthcare and state entities.

The authority is also working to meet state mandates to reduce and eliminate healthcare associated infections. The authority established a 15-member panel of infection control experts throughout Pennsylvania. The panel has been instrumental in providing guidance for the authority and Department of Health in determining the reportable infection events for hospitals and nursing homes. The authority plans to use the panel to assist in identifying training and education activities that will reduce and eliminate healthcare associated infections.

Another initiative in the plan will allow Pennsylvania’s patient safety officers to share best practices and other information through a confidential electronic forum so they can learn from one another more directly.

“So many facilities are developing and implementing great programs to improve patient safety,” Doering said. “Our goal is to help them share the information instead of having each facility reinvent the wheel.”

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