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Adverse Events Reporting Standards Boost Patient Safety in PA

Pennsylvania's patient safety reporting standards have helped boost the reporting for adverse hospital events across the state.

- The Pennsylvania Patient Safety Authority has successfully standardized and improved its patient safety reporting procedures, according to a recent press release.

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On year ago, the Authority implemented 28 standards which sought to streamline the way in which hospital workers report adverse hospital events. Ultimately, the Authority wanted to attain a more accurate picture of hospital safety events to better understand the efforts staff were putting forth to protect patients.

Leaders from the Authority say while not entirely conclusive, these standards are showing signs of success in boosting the quality of hospital safety reporting.

"The standardization project took several months with a multi-stakeholder workgroup to help develop a consensus on twenty-eight guiding principles as well as make technical changes to the Authority's reporting system to improve consistency in event reporting,” Rachel Levine, M.D. chair of the Pennsylvania Patient Safety Authority said.

"It is a work in progress in terms of analyzing the reports, but early signs indicate the implementation is working."

The Pennsylvania Patient Safety Authority developed these standards to better align with other patient safety related legislation, particularly the Medical Care Availability and Reduction of Error (MCARE) Act. The standards work to help providers determine if an incident falls within one of the following categories: serious events, incidents, infrastructure failures, or other.

As a result, the Authority had to develop several new event categories and sub-categories to better serve provider needs and to expand the scope of event reporting.

"New and revised event types and subtypes were created in the Pennsylvania Patient Safety Reporting System [PA-PSRS] to help in the standardization effort," Levine said.

"The number of reports submitted under the new event types nearly doubled between the second and third quarter of the year; and between the second and fourth quarters, the number of events submitted increased over one hundred percent."

Using frequently asked questions lists and data analysis, the Authority developed the guidelines and published a draft for public comment in 2014. As stated above, the guidelines were fully adopted by April 2015.

Overall, the implementation of these new guidelines helped boost events reporting, which ultimately helps the Authority gain a better handle on how hospitals are performing on quality and safety. The Authority saw improvements on three specific fronts:

  • there was a noticeable increase in Serious Event reports starting in April 2015, the month the new standards went into effect
  • the use of new and revised event types and subtypes promotes more consistency in reporting, which is evident with the number of reports submitted under the new event types nearly doubling since implementation
  • healthcare facilities have enthusiastically embraced education for the standardization principles.

Implementation of these guiding principles came with considerable staff training. According to Levine, the Authority wanted to see as many providers as possible educated in the new protocol in order to see maximum results.

In total, over 70 percent of member providers had completed the minimum required module training, and 423 patient safety officers, physicians, quality managers, and nurse leaders had undergone on-site standards training.

Authority members have reportedly been receptive to these new guidelines.

"The principles have found good acceptance among healthcare providers, as evidenced by the nature of the help desk calls received during implementation, the tenor of conversations among facilities and the Authority's Patient Safety Liaisons (PSLs) and an increase in Serious Event reporting," Levine added.

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