New standards double Pennsylvania patient-harm reporting

A year after a patient safety agency implemented standardized adverse event reporting procedures statewide, a new report shows improvement in self reporting at Pennsylvania hospitals. 

The Pennsylvania Patient Safety Authority (PPSA) developed the 28 standards, which seek to get a clearer, more precise picture of the state of patient safety and providers' strategies to improve it.

"It is a work in progress in terms of analyzing the reports, but early signs indicate the implementation is working," PPSA Chair Rachel Levine, M.D., said in an announcement.

In developing the standards over several months, PPSA created myriad new event categories and sub-categories in accordance with specific provider needs. Between the second and third quarter of 2015, Levine said, reports falling into one of the new categories nearly doubled, and they more than doubled in the second half of the year.

In addition to the increase in reporting under the new event types and subtypes, serious event reports spiked beginning last April, when the new standards went into effect, and hospitals and health systems have also implemented education programs for standardization of safety principles. Over the course of 2015, overall serious event reporting spiked 9 percent, according to the report, although per-month averages for incident reports fell slightly compared to 2014.

Individual providers have made similar efforts to improve patient safety transparency as well; last year, Boston's Brigham and Women's Hospital made a previously internal blog documenting medical errors and near-misses accessible to the public, FierceHealthcare previously reported. Each post excludes any information that could threaten patient privacy while providing a detailed breakdown of both how the error occurred and how to avoid it in the future. However, recent research suggests that the structure of federal incentives could punish providers who are more diligent about reporting harms or errors, FierceHealthFinance previously reported.

The news comes just days after a report found hospital medical errors remain the third-leading cause of death in the United States, while patient safety experts urge the creation of cultures of patient safety within hospitals, including extensive educational efforts.  

To learn more:
- read the report (.pdf)
- here's the announcement

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