Unique patient safety authority enables sharing of lessons learned: Pennsylvania PSA reports on serious events collected

HealthCare Benchmarks and Quality Improvement, Jan, 2005

In the past two years, three Pennsylvania hospitals have won the coveted John M. Eisenberg Patient Safety and Quality Award, given by the National Quality Forum (NQF) and the Joint Commission on Accreditation of Health Care Organizations. In addition, the latest report on the performance of Pennsylvania hospitals by the Pennsylvania Health Care Cost Containment Council (PHC4) finds a decline in patient mortality rates for all conditions reported over the last two years. The report includes risk-adjusted mortality rates, lengths of stay, and other data for patients admitted to 167 Pennsylvania hospitals from October 2002 through September 2003.

But while hospitals from other states are garnering quality and safety awards and improving outcomes, Pennsylvania also is doing something no other state has yet done: It has established a statewide Patient Safety Authority (PSA) to help health care professionals learn from events that occur, or have the potential to occur, to avoid injuries to patients in hospitals throughout the state.

No one is claiming the PSA is responsible for this spate of safety award winners--in fact, these institutions had well-established programs in place before the PSA was created two years ago--or

Key Points

* The Pennsylvania Patient Safety Authority requires hospitals to report serious events and potentially harmful events.

* Hospitals can be fined and physicians can lose licensing for failure to report events.

* More than 50,000 events have been reported statewide since the system went on-line in July 2004. that it is the main reason mortality rates have dropped in Pennsylvania. But the authority is unique; it does require that hospitals pay more attention to their patient safety efforts, and it enables sharing lessons learned by some of the safety leaders in the state.

How the PSA works

The PSA is part of a tradition started by PHC4, which was established in the mid-1980s, explains John Combes, MD, senior medical advisor for the Hospital & Health System Association of Pennsylvania (HAP). "PHC4 was a way for the state to avoid rate controls around health care and to create resources for businesses and consumers to look at health care costs and some outcomes," he explains, noting that for years it has been generating what is called the "Hospital Performance Report." (For more information, go to its web site at PHC4.org.)

"The Patient Safety Authority was established by our legislature two years ago as part of Act 13, or the Mcare act," he notes. "It involved establishment of the PSA. It introduced some basic tort reforms; and it addressed unfunded [insurance] liabilities."

The authority collects reports from hospitals on events that may have harmed patients or have the potential to harm patients. "The hospitals have to report them as they occur," Combes adds.

Both serious events and incidents must be reported. Serious events are events that occur in clinical care that affect patient safety and result in harm to the patient that requires treatment, he points out.

Incidents are events that could affect patient safety, did not harm the patient, but have the potential to harm the patient.

Reporting is not voluntary, Combes emphasizes. "For serious events, the fine is about $100 a day for failure to report, and the physician or licensee can be reported to the licensing board," he says. "But the idea is not to use the information against the facility--rather, it is for [gaining] knowledge." Serious events are shared with the Department of Health, which may in turn use them to develop new regulations.

The state has contracted with ECRI (Emergency Care Research Institute) in Plymouth Meeting, PA, to analyze the data. "They review all the reports, and then the authority issues recommendations to the field in the form of a newsletter--called Patient Safety Advisory," Combes notes.

An example of the kind of information shared is several recent reports about people confusing TB syringes with insulin syringes. "Both are about the same size, with orange caps to them," he explains. "It's an easy mix-up to make, but the gradations on the TB syringes are different.

"The beauty of this is that the report actually does the analysis of these events and then gives recommendations to the field about how they can improve care," Combes continues. The newsletter is mainly distributed electronically.

"The state has created this independent authority as a resource from which hospitals can learn," he says. "It is the first of its kind in the country, and right now it is unique; it's the only one with mandatory requirements for reporting incidents as well as serious events."

Even hospitals with well-established quality improvement programs have felt the impact of the PSA, although they also are called upon by the state to provide advice and are used to illustrate best practices.

"We've had a very active quality program in our organization for many years," says Zubina Mawji, MD, acting senior vice president for quality and care management for the Lehigh Valley Hospital and Health Network in Allentown, PA, a three-hospital system that is a 2003 Eisenberg winner.