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1. Pennsylvania: Background for State Action. Escalating Medical Malpractice Insurance PremiumsAlleged Physician ExodusThreatened Closure of Hospital-based Clinical ServicesIOM Report (1999):
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1. Pennsylvania Patient Safety Reporting System Alan B.K. Rabinowitz
Administrator, Patient Safety Authority
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2nd Annual Betsy Lehman Center Patient Safety Conference
December 5, 2005
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3. 2 Act 13: Medical Care Availability and Reduction of Error Act of 2002 To reduce and eliminate medical errors by identifying problems and implementing solutions that promote patient safety
Establishes the Patient Safety Authority
Promulgates facility-based reporting requirements
Mandates written patient notification and designation of patient safety officers, plans and committees
Administrative provisions, including patient safety CME requirements and self-reporting
Medical malpractice-related and tort reform provisions
4. 3 PA Patient Safety Authority Independent agency under an 11-member Board
Non-regulatory
Dedicated funding stream outside of the General Fund
Collects, analyzes and evaluates trends of serious events and incidents
Makes recommendations for improvements in healthcare practices
Advises facilities on matters related to patient safety
Issues an Annual Report
5. 4 PA - Reporting Components Acute Care Hospitals
Ambulatory Surgical Facilities
Birthing Centers
6. 5 PA-PSRS: Achieved Goals Implement Mandatory Reporting
Initiated June 2004; Today: 446 facilities; 220,000 reports submitted
Web-based; 21 core questions: harm score, root causes and contributing factors, recommendations for prevention
Assure Facilities’ Return on Investment
Real time feedback to individual facilities
Internal analytical tools and data export capacity
Share Lessons Learned and Best Practices: Quarterly and Supplementary Patient Safety Advisories
Annual Report
7. 6 For this layout, photos can be on the top or the bottom of the slide. For this layout, photos can be on the top or the bottom of the slide.
8. 7 Recent Advisory Topics C-Diff: A Sometimes Fatal Complication of Antibiotic Use
A Different Mindset: One Facility’s Experience with the Anonymous Report Process
Forgotten But Not Gone: Tourniquets Left on Patients
PCA By Proxy: An Overdose of Care
Skin Integrity Issues Associated with Pulse Oximetry
Medication Errors Linked to Name Confusion
When Patients Speak-Collaboration in Patient Safety
Changing the Culture of Seclusion and Restraint
Complexity of Insulin Therapy
Problems Related to Informed Consent
Risk of Fire from Alcohol-Based Solutions
Confusion between Insulin and Tuberculin Syringes (Supplementary)
The Role of Empowerment in Patient Safety
Risk of Unnecessary Gallbladder Surgery
Changing Catheters Over a Wire (Supplementary)
Abbreviations: A Shortcut to Medication Errors
Focusing on Eye Surgery
9. 8 PA-PSRS: Ongoing Goals Promote Education and Training
Root Cause Analysis: Targeted to Patient Safety Officers
Patient Safety Concepts: Culture of safety, legal principles, best practices, national initiatives: Targeted to executives, CMOs and physician champions
Promote Culture Change: Targeted to Trustees
Encourage Research
Develop Protocols Governing Access to Data
Facilitate Data Sharing
Partner with other Data Collection and Research Entities
10. 9 PSA Assessment: Lessons Learned Mandatory reporting vs. conventional wisdom
Volume indicates good “buy in”
Help-Desk queries and facility feedback = user satisfaction
Value of near-miss reporting
Encourages communication and empowerment
Application of Patient Safety Advisories
Promotes internal QI and patient safety initiatives
Everything You Need to Know You Learned from Your Grandmother
Logistics
Adequate funding
Aesop’s Fable: The Tortoise and the Hare
11. 10 PSA: Some Additional Questions Are We Safer Today than We Were in 1999?
Yes, maybe, but…..
The PA experience
Level of provider commitment
Pace of change
Same old/same old
Driving forces
Impact of S. 544 (PSQIA of 2005)
12. 11 PA Patient Safety Authority