Pennsylvania Patient Safety Reporting System

PA - PSRS Pennsylvania Patient Safety Reporting System Alan B.K. Rabinowitz Administrator, Patient Safety Authority * * * 2nd Annual Betsy Lehman Center Patient Safety Conference December 5, 2005

Pennsylvania: Background for State Action • Escalating Medical Malpractice Insurance Premiums • Alleged Physician Exodus • Threatened Closure of Hospital-based Clinical Services • IOM Report (1999): “To Err Is Human”

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

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

PA - Reporting Components Types of Events Who Reports Other Considerations Acute Care Hospitals Ambulatory Surgical Facilities Birthing Centers Near-Misses (“Incidents”) Adverse Events(“Serious Events”) [Infrastructure Failures] ------ Incidents and Serious Events to PSA Serious Events and IFs to DOH Mandatory No Individual Identifying Data Confidentiality Provisions Non-discoverable Whistleblower Protections Facility assessment

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

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 Recent Advisory Topics

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

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 PSA Assessment: Lessons Learned

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)

PA Patient Safety Authority www.psa.state.pa.us

Pennsylvania Patient Safety Reporting System