2019 Pennsylvania Patient Safety Reporting

An Analysis of Serious Events and Incidents from the Nation’s Largest Event Reporting Database

  • Shawn Kepner Patient Safety Authority
  • Rebecca Jones Patient Safety Authority
  • Regina Hoffman Patient Safety Authority
  • Caitlyn Allen Patient Safety Authority
  • Daniel Glunk Patient Safety Authority Board Member
  • Eric Weitz Patient Safety Authority Board Member
  • Stanton N. Smullens Patient Safety Authority Board Member

Abstract

Pennsylvania is the only state that requires acute healthcare facilities to report all events of harm or potential for harm. With over 3.6 million acute care event reports, the Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world. Of the 293,400 patient safety event reports submitted by Pennsylvania’s acute care facilities in 2019, 97% were from hospitals, and 3% were from ambulatory surgical facilities (ASFs).
The vast majority of these reports were Incidents (284,847), rather than Serious Events (8,553). Reporting rates for both hospitals and ASFs increased 26% from 2015 to 2019, which is likely due to changes in reporting guidance in 2015. For each of the last five years, the most frequently reported event type was “Error Related to Procedure/Treatment/Test,” (EPTT), with this event type accounting for 33% of all submitted acute care event reports in 2019. “Medication Error,” “Complication of Procedure/Treatment/Test” and “Fall” events were also reported frequently, accounting for 18%, 16%, and 11% of all submitted event reports in 2019, respectively.
The increase in reporting rates each year may reflect improvements in patient safety culture across the Commonwealth, and the analysis within this article highlights a number of areas in which continued patient safety efforts can be applied to reduce harm in acute care settings.   

Author Biographies

Shawn Kepner, Patient Safety Authority

Shawn Kepner is a statistician at the Patient Safety Authority.

Rebecca Jones, Patient Safety Authority

Rebecca Jones is the director of Data Science and Research
for the Patient Safety Authority.

Regina Hoffman, Patient Safety Authority

Regina Hoffman is the executive director of the Patient Safety Authority.

Caitlyn Allen, Patient Safety Authority

Caitlyn Allen (caiallen@pa.gov) is the director of Engagement at the Patient Safety Authority.

Daniel Glunk, Patient Safety Authority Board Member

Daniel Glunk is the vice chair of the board of the Patient Safety Authority.

Eric Weitz, Patient Safety Authority Board Member

Eric Weitz is a board member of the Patient Safety Authority.

Stanton N. Smullens, Patient Safety Authority Board Member

Stanton Smullens is the chair of the board of the Patient Safety Authority.

References

The Joint Commission. Sentinel Events. Comprehensive Accreditation Manual for Hospitals. Update 2. 2016. Jan. Available at https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/assetmanager/camh_24_se_all_currentpdf.pdf.

Adverse Events, Near Misses, and Errors. PSNet. https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors. Published September 2019. Accessed April 23, 2020.

Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002).

Rodziewicz TL. Medical Error Prevention. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499956/. Published February 5, 2020. Accessed April 23, 2020.

2 Men talking in Hospital reception area
Published
2020-05-01
How to Cite
Kepner, S., Jones, R., Hoffman, R., Allen, C., Glunk, D., Weitz, E., & Smullens, S. N. (2020). 2019 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents from the Nation’s Largest Event Reporting Database. Patient Safety , 2(1), 8. https://doi.org/10.33940/data/2020.6.1
Section
PA-PSRS - Event Report Analyses 2019
Bookmark and Share