2020 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents from the Nation’s Largest Event Reporting Database

Authors

DOI:

https://doi.org/10.33940/data/2021.6.1

Keywords:

acute care, patient safety, annual report, incidents, serious events, reporting rates, fall rates, COVID-19

Abstract

Pennsylvania is the only state that requires acute healthcare facilities to report all events of harm or potential for harm. With over 3.9 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 278,548 patient safety event reports submitted by Pennsylvania’s acute care facilities in 2020, 97.2% were from hospitals and 2.7% were from ambulatory surgical facilities (ASFs). The remaining 0.1% were from birthing centers and abortion facilities.

The vast majority of the 2020 reports were Incidents (97.0%) rather than Serious Events (3.0%). For each of the last five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, accounting for 32.1% of all submitted acute care event reports in 2020. The second, third, and fourth most frequently reported event types were Medication Error, Complication of Procedure/Treatment/Test, and Fall, accounting for 16.7%, 16.2%, and 11.8% of submitted reports in 2020, respectively.

The reporting rates for hospitals in Q1 and Q2 2020 were 32.8 and 31.5 reports per 1,000 patient days, respectively. For ASFs, the reporting rates for Q1 and Q2 2020 were 9.8 and 8.4 reports per 1,000 surgical encounters, respectively.

Author Biographies

Shawn Kepner, MS, Patient Safety Authority

Shawn Kepner (shawkepner@pa.gov) is a statistician at the Patient Safety Authority.

Rebecca Jones, MBA, RN, Patient Safety Authority

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

References

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

Kepner S, Jones R, Allen C, Glunk D, Weitz E, Smullens S. 2019 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents From the Nation’s Largest Event Reporting Database. Patient Saf. 10.33940/data/2020.6.1.

Taylor M, Kepner S, Gardner L, Jones R. Patient Safety Concerns in COVID-19–Related Events: A Study of 343 Event Reports From 71 Hospitals in Pennsylvania. Patient Saf. 16-27. 10.33940/data/2020.6.3.

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Published

2021-04-30

How to Cite

Kepner, S., & Jones, R. (2021). 2020 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents from the Nation’s Largest Event Reporting Database. Patient Safety, 3(2), 6–21. https://doi.org/10.33940/data/2021.6.1

Issue

Section

PA-PSRS - Event Report Analyses 2020
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