Pennsylvania Patient Safety Authority Data Shows High Harm Events in Pennsylvania Healthcare Facilities Decreased Forty-Five Percent Since 2005

HARRISBURG, Pa., April 30, 2015 /PRNewswire-USNewswire/ -- High harm events in Pennsylvania healthcare facilities have decreased 45 percent since 2005 as shown in data published in the Pennsylvania Patient Safety Authority's 2014 Annual Report released today.

"High harm events according to Pennsylvania reporting requirements fall into one of three categories: events that occurred and resulted in permanent harm to the patient; events that occurred and resulted in a near-death event; or events that resulted in a patient's death," said Rachel Levine, M.D., acting chair of the Pennsylvania Patient Safety Authority board of directors.  "In 2014, the data relating to patient deaths shows that events from hospitals that may have contributed to or resulted in the patient's death decreased by 13 reports [six percent] since 2013. 

"And for last year, the data shows that Serious Events and Incidents have decreased on average four hundred and eighty-six reports per month," Levine added. 

For every report submitted through the Pennsylvania Patient Safety Reporting System (PA-PSRS), the healthcare facility applies a 10-item scale to measure whether an event reached the patient and, if so, how much harm it caused. This scale ranges from "unsafe conditions" (e.g., look-alike medications stored next to one another) to the death of a patient.

Levine said in 2014 Pennsylvania acute healthcare facilities submitted 240,778 reports through PA-PSRS, bringing the number of reports submitted since the program's inception in 2004 to 2,271,370.

For a detailed overview of data reported through PA-PSRS in 2014 that includes breakdowns of reports by event type and region, go to Addendum B in the Authority's 2014 Annual Report at www.patientsafetyauthority.org.

Levine said this year the flagship publication of the Authority, the Pennsylvania Patient Safety Advisory, turned 10 years old.

"The Pennsylvania Patient Safety Advisory provides timely, original scientific evidence about what problems are occurring in Pennsylvania healthcare facilities, Levine said. "But more importantly, the Advisory also provides potential solutions to those problems through its research of safe healthcare practices."

The Authority has published over 475 Advisory articles and developed 47 accompanying educational toolkits to help healthcare facilities improve system processes. Over 4,100 documented changes have occurred in Pennsylvania acute care facilities and nursing homes that are directly attributed to Advisory articles since 2005.

"The Advisory continues to receive high marks from hospitals and nursing homes for its usefulness, relevance, readability, scientific quality and educational value," Levine added. "Healthcare professionals have obtained almost twelve thousand continuing education credits from studying the Advisory.

"In 2014, the Authority website received over one million hits with over five hundred thousand Advisory hits and over one hundred thousand educational toolkit hits" Levine added.

Advisory readership includes subscribers in all 50 states, plus DC, the Virgin Islands, Puerto Rico, and other US territories. Worldwide the Advisory has over 4,500 subscribers in 44 countries.

For more information about the Pennsylvania Patient Safety Advisory, including articles published in 2014, go to Addendum C in the Authority's 2014 Annual Report at www.patientsafetyauthority.org.

Levine said educational programs through the Authority's Patient Safety Liaison (PSL) program continued in 2014.

"The Patient Safety Liaison program continues to provide Pennsylvania healthcare facilities with their own personal link to the Authority to help improve patient safety within their facilities," Levine said. "Each PSL serves as an educator and consultant to their assigned facilities, providing on-site educational programs, assisting in collaborative work, analyzing patient safety events and providing methods for improvement."

Levine said in addition to conducting 189 educational sessions to healthcare professionals, PSLs made over 900 visits to individual healthcare facilities with a total of 9,896 healthcare professionals educated through the PSL program and webinars in 2014.

"Throughout the year, PSLs continuously obtain feedback from their facility visits and education sessions to tailor the programs the Authority offers," Levine said. "New programs are added each year to provide the most comprehensive educational sessions."

PSLs also facilitate networking sessions for Patient Safety Officers (PSOs) and guests routinely throughout the state. The sessions offer PSOs and their guests an opportunity to discuss common patient safety issues and share solutions and improvement practices. Educational topics of the networking sessions in 2014 include: Workplace Violence—Active Shooter, Human Factors in Ambulatory Surgery, Breakdowns in the Medication Reconciliation Process, Aligning the Lines: An Analysis of Intravenous Line Errors, Distractions in the Operating Room, and a Systems and Behavioral Approach to Improve Hand Hygiene.

For more detailed information on the Authority's PSL program and education sessions, go to Addendum D in the 2014 Annual Report at www.patientsafetyauthority.org.

Levine said the Authority continued its collaborative efforts, some as part of the Centers for Medicaid and Medicare Services (CMS) Hospital Engagement Network's (HEN) Partnership for Patients (PfP) campaign. The PfP campaign focuses on reducing healthcare-acquired conditions with goals to keep patients from getting injured or sicker and to help patients heal without complication.

"Through the PfP campaign, the Authority has worked with over one hundred and thirty Pennsylvania healthcare facilities and the Pennsylvania Hospital and Healthsystem Association [HAP] to decrease adverse drug events with opioids, falls and wrong-site surgery," Levine said. "Overall, the PA-HEN project resulted in a thirty-seven percent reduction in preventable harm."

Levine said while the work with the HAP PA-HEN utilized the majority of the Authority's collaborative resources in 2014, the Authority was able to begin a collaborative project with long-term care facilities to prevent catheter-associated urinary tract infections (CAUTIs). The Authority also fostered collaborative partnerships with the Philadelphia Department of Health (hemodialysis infection prevention) and the Quality Insights Quality Improvement Network (reduce healthcare-associated infections through best practice implementation).

For more information on the Authority's collaborations, go to Addendum E in the 2014 Annual Report at www.patientsafetyauthority.org.

Levine said in 2014 the Authority continued its education efforts for preventing healthcare-associated infections (HAI) in Pennsylvania healthcare facilities and nursing homes.

"The Authority educated over fifteen hundred healthcare professionals from various healthcare facilities, groups and organizations on how to prevent healthcare-associated infections," Levine said. "For the first time in 2014, the Authority offered an online learning program to educate Pennsylvania long term care providers on the newly released McGeer criteria for infection reporting."

The Authority also received feedback from long-term care providers on an evidence-based best practice assessment tool developed for them in 2011. Over 90 percent of long-term care facility respondents praised the tool for helping to: increase IPD job performance, increase staff knowledge, direct infection prevention focus areas, increase interest in patient safety and decrease infections.

Nursing homes also received a new suite of analytical tools developed by the Authority for PA-PSRS so facilities can analyze reported infection data down to the unit level," Levine added. "The Authority also introduced a Learning Management System [LMS] to provide training for PA-PSRS nursing home users which contains interactive web-based modules available twenty-four hours a day, seven days a week."

For more information about the education efforts to reduce HAIs go to Addendum F in the Authority's 2014 Annual Report at www.patientsafetyauthority.org.

Levine said the Authority's campaign to recognize Pennsylvania healthcare workers' patient safety efforts is also highlighted in the 2014 Annual Report.

The "I Am Patient Safety" poster contest highlights individuals and groups within Pennsylvania healthcare facilities who have made a personal commitment to patient safety. The contest is held annually with winners announced in the March Pennsylvania Patient Safety Advisory.

Submissions for the poster contest were judged upon the following criteria: The person or group 1) had a discernible impact on patient safety for one or more patients, 2) demonstrated a personal commitment to patient safety, and 3) demonstrated that a strong patient safety culture is present in the facility. Bonus points were awarded for submissions that demonstrated initiative taken by an individual.

"One of my first duties as acting chair of the Authority's board of directors was to congratulate the poster winners for their efforts to improve patient safety within their healthcare facilities," Levine said. "Often the Authority's work through the Patient Safety Advisory is to tell facilities what they are doing wrong and how to fix it. Through this recognition campaign, the Authority can tell healthcare workers what they are doing right and congratulate them on a job well done."

For more information about the Authority's poster campaign to recognize patient safety efforts go to Addendum G of the 2014 Annual Report at www.patientsafetyauthority.org.  

The complete Annual Report for 2014, as well as additional information about the Pennsylvania Patient Safety Authority, is accessible on the Authority's website www.patientsafetyauthority.org.

SOURCE Pennsylvania Patient Safety Authority

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