Pennsylvania Patient Safety Authority Issues Annual Report for 2011

The report highlights increases in its educational programs and collaboration efforts to improve patient safety within Pennsylvania's healthcare facilities

HARRISBURG, Pa., April 30, 2012 /PRNewswire-USNewswire/ -- The Pennsylvania Patient Safety Authority issued its 2011 Annual Report highlighting increases in its educational programs and collaborations that focus on topics such as preventing wrong-site surgery and decreasing healthcare-associated infections.

"In 2011, the Patient Safety Authority broadened its scope of educational activities by increasing the number of educational courses and collaborations to include areas such as reducing healthcare-associated infections in ambulatory surgical facilities," Stanton N. Smullens, M.D., acting chair of the Pennsylvania Patient Safety Authority said. "Because of the increase in educational programs and the Patient Safety Liaison program, the attendance at the educational programs has more than doubled."

The Patient Safety Liaison (PSL) program began in August 2008. Overseen by the Authority's Director of Educational Programs, each PSL has between 65-100 healthcare facilities that they meet with regularly to ensure the Patient Safety Officers (PSOs) are aware of the valuable resources available to them from the Authority and other patient safety leaders.

"The positive, collegial relationships the PSLs have developed with PSOs enables the Authority to work closely with the healthcare facilities to develop educational programs and collaborations that are needed to improve patient safety in specific areas," Smullens said. "Some new educational programs offered in 2012 include training healthcare facility staff to investigate patient safety problems, Just Culture™ and using teamwork and communication to improve patient safety.

"Through the PSL program, relationships among competing healthcare facilities have also improved because of the common goal to improve safety in areas such as preventing mislabeling of blood samples and wrong-site surgery," Smullens added. 

Through a U.S. federal grant program called "Partnership for Patients," the Authority has partnered with the Hospital and Healthsystem Association of Pennsylvania (HAP) and will receive approximately $1.6 million over two years to focus statewide on decreasing falls, wrong-site surgery and adverse drug events.

"The Authority was poised to take the wrong-site surgery and falls collaborations statewide after successful regional efforts in reducing these events," Smullens said. "The federal grant gave the Authority the revenue needed to do all three simultaneously."

Smullens said one regional collaborative with 19 healthcare facilities eliminated all wrong-site surgeries in operating rooms for over one year and a regional falls collaborative reduced harmful falls by 31 percent.

Other acute care collaborations sponsored by the Authority include programs to improve the preoperative screening and assessment process in ASFs and to help prevent surgical-site infections. 

For more information about the Authority's educational programs and collaborations go to Addendums E and F in the 2011 Annual Report at www.patientsafetyauthority.org.

Smullens said the Annual Report also highlights efforts to combat healthcare-associated infections in nursing homes. "Last year, the Authority assessed ten nursing homes to determine how they prevent healthcare-associated infections," Smullens said. "The program gave the Authority valuable information on the structure and function of nursing home infection control programs by measuring the level of implementation in several key areas like hand hygiene, process monitoring, and environmental measures to prevent infections that occur in the nursing home environment."

Smullens said that controlling the threat of annual norovirus outbreaks was also an educational initiative in 2011. In an annual survey, 25 percent of nursing homes responded that a norovirus Patient Safety Advisory article led to changes in their facility and over 40 percent of respondents said they had incorporated the Authority's "Norovirus Preparedness Checklist Tool" into their education protocol design, team development, policy changes and early response activities. Norovirus prevention posters were also distributed to nursing homes for healthcare workers and consumers on how to prevent and control outbreaks.

Smullens said the Authority also joined a multi-agency collaboration to improve healthcare worker vaccination rates.

"Less than sixty-five percent of healthcare workers get vaccinated annually," Smullens said. "Research shows low healthcare worker vaccination rates have been linked to hospital influenza outbreaks."

Smullens said Authority research shows nursing homes with mandatory worker vaccination programs had 22% lower combined seasonal lower respiratory tract/influenza-like illness rates from October 2010 through March 2011.

"The Authority research shows that over nineteen hundred respiratory tract infections could have been prevented if all Pennsylvania nursing homes had mandatory worker vaccination programs in place," Smullens said. "The Authority will continue to educate nursing homes on its findings and the importance of mandatory vaccination programs in preventing infections."

Other healthcare-associated infection topics published in Advisory articles in 2011 include: skin and soft tissue infections in long-term care, preventing bloodborne disease transmission associated with unsafe infection practices and central-line-associated bloodstream infection prevention.

For more information about events data and healthcare-associated infection data in hospitals and nursing homes go to Addendum H of the 2011 Annual Report at www.patientsafetyauthority.org. 

Other Highlights of the Authority's 2011 Annual Report include:

2011 Detailed Overview of Data Reported Through PA-PSRS

Between January 1 and December 31, 2011, Pennsylvania acute care facilities submitted 228,835 reports through the Pennsylvania Patient Safety Reporting System (PA-PSRS). To date, over 1.5 million reports have been submitted through PA-PSRS. Approximately, 3.5 percent were Serious Events (events that caused harm), while 96.5 percent were Incidents or near-misses (events that did not cause harm).

"Overall, reporting in 2011 increased for Serious Events [7%] and Incidents [1%]," Smullens said. "The majority of the Serious Event increase can be attributed to an increase [11%] in reports related to complications of procedures/treatments/tests.

For more details about the Authority data and breakdowns by event type, gender and age groups go to Addendum B of the 2011 Annual Report.

2011 Annual User Survey Results

Facilities continue to make changes to improve patient safety according to the Authority's annual user survey. In November 2011, the Authority asked registered primary contacts at healthcare facilities in Pennsylvania to participate in an online survey. Those contacts include: Infection Prevention Designees (IPDs) and PSOs.

"Facilities continue to find Patient Safety Advisories useful [99%], relevant [98%], readable [100%], high in scientific quality [100%] and high in educational value [100%]," Smullens said. "Also, almost all of the respondents [99%] rated the PSL program as valuable."

For more information on the annual user survey, go to Addendum G of the 2011 Annual Report.

Summaries of Selected 2011 Advisory Articles

The Pennsylvania Patient Safety Authority distributes its Pennsylvania Patient Safety Advisory to more than 5,700 program affiliates (i.e., acute healthcare facilities, nursing homes, board and panel members in Pennsylvania) as of December 31, 2011. 

"Since the first Advisory article was issued in March 2004, the Authority has published more than three hundred and ninety articles on a variety of clinical issues," Smullens said. "The award-winning Advisory continues to garner statewide, national and worldwide support for its clinical research."

In 2011, the Authority published four quarterly issues, containing 34 articles. Topics of articles include: Medication Errors in the Emergency Department, Falls in Radiology, Skin and Soft Tissue Infections in Long-Term Care, Reducing Errors in Blood Specimen Labeling and Applying the Universal Protocol to Improve Patient Safety in Radiology Services. 

For more information about the Pennsylvania Patient Safety Advisory and subscribers, go to Addendums C and D of the 2011 Annual Report.

The complete Annual Report for 2011, as well as additional information about the Patient Safety Authority, is accessible on the Authority's website www.patientsafetyauthority.org.

SOURCE Pennsylvania Patient Safety Authority