PA - PSRSPA - PSRS

Pennsylvania Patient Safety Reporting System

Alan B.K. RabinowitzAdministrator, Patient Safety Authority

2006 National Health Policy Conference February 7, 2006

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ObjectivesObjectives

• Background on Pennsylvania’s mandatory reporting statute

• The PA-PSRS System

• Sharing Data

• Lessons Learned

• Assessment after 18 months

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Pennsylvania: Background for State ActionPennsylvania: 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 1864From 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 TwainSan Francisco Morning CallOctober 1, 1864

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Act 13: Medical Care Availability and Reduction of Error Act of 2002Act 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 AuthorityPA 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 ComponentsPA - Reporting Components

Acute Care Hospitals

Ambulatory Surgical Facilities

Birthing Centers

Who Reports

Mandatory

No Individual Identifying Data

Confidentiality Provisions

Non-discoverable

Whistleblower Protections

Facility assessment

Other Considerations

Near-Misses (“Incidents”)

Adverse Events (“Serious Events”)

[Infrastructure Failures]

------

Incidents and Serious Events to PSA

Serious Events and IFs to DOH

Types of Events

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Report IntakeReport Intake

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Anonymous Reports of Serious EventsAnonymous Reports of Serious Events

• Only applies to Serious Events

• Must be submitted by a healthcare worker

• Event must first be reported through facility’s reporting process

• Verification and possible review by Authority

• Referral to Department of Health for failure to report

• Whistleblower protection

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RoadblocksRoadblocks

• Complex IT project

• Pennsylvania’s 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 DevelopmentSystem Development

• Five-year $10.5 million contract

• Data collection and analysis

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System DesignSystem 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)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 AnalysisPA-PSRS: Clinical Analysis

Analytics

TriagePatient Safety

Review Meeting

Contact with Individual Facilities

Public Advisories and Recommendations

PSA Annual Report

Program Outputs

Incoming Reports

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PA-PSRSPA-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 TopicsRecent Advisory Topics

• Use of Color-Coded Wristbands Creates Unnecessary Risk (Supplementary)

• Unanticipated Care after Discharge from ASF’s

• 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)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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StatisticsStatistics

Event Type PA-PSRS

Medication Error 25%

Adverse Drug Reaction 2%

Equipment/Supplies/Devices 2%

Falls 21%

Error Related to Procedure / Treatment / Test 19%

Transfusion 1%

Complication of Procedure / Treatment / Test 15%

Skin Integrity 8%

Other / Miscellaneous 7%

PA-PSRS n = 243,474(as of 01/07/06)

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Patient Safety LessonsPatient 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)Colors Used in Wristbands (Dec 2005 Survey)

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PSA: AssessmentPSA: 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

• Aesop’s Fable: The Tortoise and the Hare

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PA-PSRS: Ongoing GoalsPA-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-PSRSComments About PA-PSRS

“I think we’re going to see in the Pennsylvania model a way to use mandatory reporting in a positive way that will make a difference.”

Lucian Leape, MDHarvard University

“Pennsylvania [has implemented] new patient safety initiatives that are seen as among the most progressive in the nation.”

Philadelphia InquirerJune 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-PSRSComments About PA-PSRS

“Pennsylvania’s 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, MDPast PresidentPennsylvania Medical Society

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Culture of SafetyCulture 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 AuthorityPA Patient Safety Authority

www.psa.state.pa.us