Patient Safety Trends in 2021: An Analysis of 288,882 Serious Events and Incidents From the Nation’s Largest Event Reporting Database




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


Visual abstract

Background: Pennsylvania is the only state that requires acute care facilities to report all events of harm or potential for harm. With over 4.2 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. This study examines patient safety event reports submitted to the PA-PSRS acute care database in 2021.

Methods: We queried PA-PSRS for all event reports submitted by Pennsylvania acute care facilities during calendar year 2021. We also obtained the most current data from the Pennsylvania Health Care Cost Containment Council (PHC4) to calculate rates based on patient days for hospitals and surgical encounters for ambulatory surgical facilities (ASFs). For the Other (specify) subtype within the Other/Miscellaneous event type, we identified the words occurring most frequently in the required free-text response field and calculated the increase in associated reports for each of the words from 2020 to 2021.

Results: Of the 288,882 patient safety event reports submitted by Pennsylvania’s acute care facilities in 2021, 96.8% were from hospitals and 3.1% were from ASFs. The remaining 0.1% were from birthing centers and abortion facilities. The vast majority of the 2021 reports were Incidents (96.9%) rather than Serious Events (3.1%). For each of the past five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, accounting for 31.3% of all submitted acute care event reports in 2021. The second, third, and fourth most frequently reported event types were Medication Error, Complication of Procedure/Treatment/Test, and Fall, accounting for 16.9%, 15.3%, and 12.3% of submitted reports in 2021, respectively. The reporting rate for hospitals in 2021 (Q1 and Q2) was 30.9 reports per 1,000 patient days. For ASFs, the reporting rate in 2021 (Q1 and Q2) was 8.6 reports per 1,000 surgical encounters.

Conclusions: There was an increase in the total number of patient safety event reports submitted in 2021, yet the percentage of high harm reports remained steady. Four event types—Error Related to Procedure/Treatment/Test, Medication Error, Complication of Procedure/Treatment/Test, and Fall—accounted for more than three-quarters of all reports submitted to PA-PSRS in 2021. Readers can use the longitudinal and categorical insights shared in this article to focus patient safety improvement efforts.

Author Biographies

Shawn Kepner, MS, Patient Safety Authority

Shawn Kepner ( is a statistician at the Patient Safety Authority.

Rebecca Jones, MBA, RN, Patient Safety Authority

Rebecca Jones is director of Data Science and Research at the Patient Safety Authority (PSA) and founder and director of the PSA’s Center of Excellence for Improving Diagnosis.


Pennsylvania Department of Health. Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002). DOH website. Published 2002. Accessed April 12, 2022.

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.

Acute Care article on blue abstract backgound.



How to Cite

Kepner, S., & Jones, R. (2022). Patient Safety Trends in 2021: An Analysis of 288,882 Serious Events and Incidents From the Nation’s Largest Event Reporting Database. Patient Safety, 4(2), 18–33.



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