Pennsylvania Patient Safety Authority releases annual report

In its 2008 report about patient safety practices in the state of Pennsylvania, The Pennsylvania Patient Safety Authority (PPSA) has seen some improvement among the five domains it measured, but says there is still room for bettering patient safety leadership and reporting practices.


The 2008 Annual Report focuses on five healthcare domains that the Authority data shows need process changes for improved patient safety and ultimately a reduction in medical errors: leadership and patient safety, medication safety, safe surgery, infection prevention and device safety. Much of this report is based on information derived from a survey given to Pennsylvania healthcare facilities reporting under Act 13 of 2002 and Act 30 of 2006. While measuring patient safety is difficult for any organization, the Authority attempts to establish a baseline through the survey process for future annual reports, ongoing analysis and education initiatives.


The PPSA conducted a survey this year in which a total of 200 Pennsylvania healthcare facilities participated, including 118 hospitals. Highlights include:

•· Approximately 96% of all reports were Incidents, or did not cause harm to the patient; approximately 4% of all reports were Serious Events, which indicates that the patient received some level of harm, ranging from minor, temporary harm to death.

•· The number of Incident reports averaged 17,602 per month, an increase of 3% from 2007. Serious Event reports averaged 720 per month, representing a 19% increase from 2007. A significant portion of this increase can be traced to healthcare-associated infections reported by law as a Serious Event earlier in the year as a result of Act 52 of 2007.

•· Statewide, the most frequently reported events in hospitals involved Errors related to Procedures/Treatments/Tests (23%) and Medication Errors (22%). However, Errors related to Procedures/Treatments/Test comprise only 8% of reports involving harm or death and Medication errors comprise only 4% of events involving harm and 1% of events contributing to or resulting in death.

•· Patients over age 65 were especially vulnerable to Serious Events and Incidents, representing more than half (52%) of all reports submitted to the Authority. In 2008, approximately 60% of all Falls and 73% of all reports related to Skin Integrity involved older patients. Falls reports for older patients are down by 4% since mandatory reporting began in 2004. Skin integrity reports remain the same. Skin integrity reports include pressure sores, bruises and other skin-related conditions.


To find the full report, click here, and to view the press release, click here.


(SOURCE: HCPro Patient Safety Monitor,, May 6, 2009)