Pennsylvania Patient Safety Reporting System

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Pennsylvania Patient Safety Reporting System

• Alan B.K. Rabinowitz
• Administrator, Patient Safety Authority

2006 National Health Policy Conference
February 7, 2006
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Objectives

• Background on Pennsylvanias mandatory reporting
  statute
• The PA-PSRS System
• Sharing Data
• Lessons Learned
• Assessment after 18 months

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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
• Public Expectations

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Slide courtesy of
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From Mark Twain 1864
It would be a good thing for the world at large,
however unprofessional it might be, if medical
men were required by law to write out in full
the ingredients named in their prescriptions.
Let them adhere to the Latin, or Fejee, if they
choose, but discard abbreviations, and form
their letters as if they had been to school one
day in their lives, so as to avoid the
possibility of mistakes on that
account. Mark Twain San Francisco
Morning Call October 1, 1864
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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

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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

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PA - Reporting Components
Who Reports
Types of Events
Other Considerations
Near-Misses (Incidents) Adverse Events
(Serious Events) Infrastructure Failures
------ Incidents and Serious Events to
PSA Serious Events and IFs to DOH

• Acute Care Hospitals
• Ambulatory Surgical Facilities
• Birthing Centers

Mandatory No Individual Identifying
Data Confidentiality Provisions Non-discoverable W
histleblower Protections Facility assessment
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Report Intake
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Anonymous Reports of Serious Events

• Only applies to Serious Events
• Must be submitted by a healthcare worker
• Event must first be reported through facilitys
  reporting process
• Verification and possible review by Authority
• Referral to Department of Health for failure to
  report
• Whistleblower protection

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Roadblocks

• Complex IT project
• Pennsylvanias population distribution
• 420 facilities
• Legislative expectations and media scrutiny
• Time Sensitivity
• Perceived Solution to Med/Mal crisis
• Public confusion between learning and
  accountability

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System Development

• Five-year 10.5 million contract
• Data collection and analysis

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System Design

• Web-based
• Based on UHC Patient Safety Net
• User-friendly
• Real-time feedback
• Internal analytical tools
• Data export capacity
• Interface development
• No additional user costs

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Pennsylvania Patient Safety Reporting System
(PA-PSRS)

• Report Intake
• 21 Core Questions
• Patient Age / Gender
• Location
• Event type
• Level of harm, contributing factors and root
  causes
• Several narrative fields
• Recommendation to prevent future occurrence
• Additional Event Detail Questions
• 15 Major categories, 233 sub categories
• 250 Specific Event Types

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PA-PSRS Clinical Analysis
Incoming Reports
Triage
Patient Safety Review Meeting
Analytics
Program Outputs
Contact with Individual Facilities
Public Advisories and Recommendations
PSA Annual Report
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PA-PSRS

• Report Output
• Real time feedback to facilities
• Patient Safety Advisories
• Annual Report
• Related Activities
• Education and Outreach
• Research
• Promotion of Culture of Safety and Full and Open
  Disclosure

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Recent Advisory Topics

• Use of Color-Coded Wristbands Creates Unnecessary
  Risk (Supplementary)
• Unanticipated Care after Discharge from ASFs
• The Beers Criteria Medication Screening in the
  Elderly
• Hidden sources of Latex in Healthcare Products
• Use of X-Rays for Incorrect Needle Counts
• Patient Identification Issues
• Falls Associated with Wheelchairs
• Medication Errors Linked to Name Confusion
• When Patients Speak-Collaboration in Patient
  Safety
• Anesthesia Awareness

• Dangerous Abbreviations in Surgery
• Problems Related to Informed Consent
• Focus on High Alert Medications
• Bed Exit Alarms to Reduce Falls
• 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
• Lost Surgical Specimens

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Annual Report for 2004 (Issued May 2005)

• 70,000 Reports in 6 Months
• 95 Reports Events without harm
• 35 of Facilities Implemented New Procedures in
  Response to PA-PSRS
• Falls and Medication Errors Largest Number of
  Reports
• Procedure Complications Largest Number of
  Reports with Harm
• 59 of Events with Harm Involve Elderly
• (cf 41 of Inpatient Hospitalization Elderly)

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Statistics
PA-PSRS n 243,474 (as of 01/07/06)
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Patient Safety Lessons

• Patient Identification
• High Alert Medications
• Drugs Associated with Falls
• Informed Consent is No Excuse
• Syringe Confusion
• Unlabeled Bowls in Surgery
• Abbreviations
• Errors Related to IT
• Hospital Acquired Infections
• Wristband Confusion
• Stress Management

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Supplementary Advisory
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Colors Used in Wristbands (Dec 2005 Survey)
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PSA Assessment

• 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 / shared
  learning
• Promotes internal QI and patient safety
  initiatives
• Everything You Need to Know You Learned from Your
  Grandmother
• Logistics
• Adequate funding
• Aesops Fable The Tortoise and the Hare

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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

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Comments About PA-PSRS
I think were going to see in the Pennsylvania
model a way to use mandatory reporting in a
positive way that will make a difference. Lu
cian Leape, MD Harvard University Pennsylva
nia has implemented new patient safety
initiatives that are seen as among the most
progressive in the nation. Philadelphia
Inquirer June 1, 2004 Recipient of 2004
Healthcare IT Innovator Award from Healthcare
Informatics magazine (September 2004
issue) Published by McGraw-Hill
Companies
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Comments About PA-PSRS
Pennsylvanias health care providers and
patients are fortunate to have their safeguards
championed by the Patient Safety Authority....By
implementing the Pennsylvania Patient Safety
Reporting System, the Authority has begun to
assist health care systems in successfully
identifying and correcting their
shortcomings....Patients and health care
providers are benefiting from the efforts of this
pioneering group. William W. Lander,
MD Past President Pennsylvania Medical
Society
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Culture of Safety

• The ultimate success of the PA-PSRS system is not
  in the number of reports we receive, but in how
  facilities and individual providers use the
  information within those reports to improve
  patient care.

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