Patient Safety Authority Issues Annual Report for 2007

The Authority in 2007 developed and began implementing a Strategic Plan while facilities continued to use guidance in Patient Safety Advisories to improve patient safety while implementation of Act 52 to eliminate infections in hospitals and nursing homes began

HARRISBURG, Pa., April 30 /PRNewswire-USNewswire/ -- The Pennsylvania Patient Safety Authority released its 2007 Annual Report today outlining its Strategic Plan that aligns its activities more closely with its educational and quality improvement mission. Also, facilities increased reporting and continued to make changes based on guidance in Patient Safety Advisories.

"The Patient Safety Authority had a full year last year and this year will be just as active if not more so," Mike Doering, executive director of the Pennsylvania Patient Safety Authority said. "The initiatives in our Strategic Plan once fully implemented will help to improve patient safety in Pennsylvania."

The plan increases the Authority's focus on education and collaboration and identifies several multi-year initiatives, some of which were developed based on feedback from focus groups held with Pennsylvania Patient Safety Officers. Selected initiatives are aimed at educating Boards of Trustees in their role in promoting patient safety, creating an online forum for more routine sharing of best practices and lessons learned among Patient Safety Officers and creating a Patient Safety Liaison pilot program that will offer healthcare facilities on-site education or quality improvement assistance from the Patient Safety Authority.

Other immediate plans for the Authority include hiring a Director of Educational Programs. The Director of Educational Programs will direct the Authority's statewide and regional education and training programs and help develop educational materials for facilities to utilize. This person would also supervise the regional Patient Safety Liaisons.

"Many Patient Safety Officers have asked for more of a presence from the Patient Safety Authority to help them implement patient safety initiatives," Doering said. "We recognize that while every facility shares the same goal to improve patient safety, each facility faces different obstacles in achieving that goal. These new Authority employees will work with facilities on a more individual basis to help them achieve their patient safety goals."

Doering added that several of the initiatives require collaboration with other healthcare and state entities.

"We're working with the Hospital and HealthSystem Association to implement a pilot program to educate hospital trustees and top-line management and we've been working with the Department of Health, Governor's Office of Healthcare Reform and Pennsylvania Healthcare Cost Containment Council to implement Act fifty-two to reduce and eliminate healthcare associated infections," Doering said.

Through Act 52 the Authority established a 15-member panel of infection control experts throughout Pennsylvania. The panel has been instrumental in providing guidance for the Authority and Department of Health in determining the reportable infection events for hospitals and nursing homes. The Authority plans to use the panel to assist in identifying training and education activities that will reduce and eliminate healthcare associated infections.

Another initiative in the plan will allow Pennsylvania's Patient Safety Officers to share best practices and other information through a confidential electronic forum so they can learn from one another more directly.

"So many facilities are developing and implementing great programs to improve patient safety," Doering said. "Our goal is to help them share the information instead of having each facility reinvent the wheel."

The Authority will also work towards improving the consistency in the number of reports received through PA-PSRS. The data in the 2007 Annual Report shows that there is substantial variation in the number of reports submitted by different healthcare facilities. While a vast majority of hospitals are reporting Serious Events (events that cause harm to the patient) and Incidents (events that do not cause harm to the patient); the volume varies greatly from facility to facility.

Doering said the Authority believes the main reason facilities are reporting inconsistently is because there are differences among them regarding how to interpret language in Act 13 as to what is reportable. He added that the Authority will work with the Department of Health, which is the state regulator of reporting, to offer facilities more guidance as to what should be reported to bridge the gap in facility reporting levels. The inconsistency is of concern to the Authority.

"These differences in reporting by different types of facilities is concerning for several reasons," Doering said. "If events aren't reported, we may be missing opportunities to share information that could help to prevent similar events from happening in other facilities."

"Another concern is that when facilities have different interpretations of the Serious Event definition, a patient who would receive written notification if they were harmed in one facility might not be notified if they were in another facility," Doering added. "It is important for open communication to occur between the patient and provider when a Serious Event occurs so that everyone understands what happened."

He explains that according to Act 13 when a Serious Event occurs in a facility the patient that suffered from the Serious Event must receive written notification from the facility explaining what happened. The provision was added in Act 13 to encourage providers to communicate more openly with their patients.

Doering said many facilities have been asking for further guidance about reporting. The Authority has provided facilities with program memoranda to help them interpret what should be reported. (e.g. Facilities should not consider an event as not reportable simply because it is listed on the patient consent form as a possible occurrence.)

Since these efforts have not proven to substantially decrease reporting variability, Doering said the Authority has made standardization a goal in its 2007 Strategic Plan which can be found on page 14 in its annual report (link below).

To accomplish this goal, the Authority will do the following:

-- We will work with the Department of Health to explore both organizations' interpretations of Act 13 requirements, with the goal of providing interpretive guidance that can be used by facility Patient Safety Committees and Department of Health surveyors.

-- We are working with healthcare facilities in the Delaware Valley through the Health Care Improvement Foundation to improve reporting consistency for selected types of events.

-- We will give guidance to healthcare providers on disclosure of adverse events to patients and their families.

-- We will perform a comparative analysis of healthcare facilities that are high-and low-volume reporters in an effort to determine what organizational characteristics encourage a greater level of reporting. We will distribute our findings through the Pennsylvania Patient Safety Advisory.

-- A consumer tips sheet is available to further educate patients on the Authority and what is a Serious Event and Incident.

Also in the 2007 Annual Report is the executive summary that gives readers a breakdown of what is contained in the report in a nutshell. As mentioned, more reports were submitted in 2007 than any other previous year. An Advisory article highlighting the problem with wrong-site surgeries made national news and continues to garner interest in the healthcare community. The Authority also continued to offer educational toolkits and consumer tips sheets with each Advisory for further guidance. A Failure Mode and Effects Analysis course was also offered in 2007 to educate facilities on how to examine their current processes for any potential gaps that could cause a Serious Event or Incident.

An Executive Summary of the 2007 Annual Report is attached to this press release. For the complete 2007 Annual Report, go to, or click on the following link

Executive Summary

The Patient Safety Authority is an independent state agency established under Act 13 of 2002, the Medical Care Availability and Reduction of Error "Mcare" Act. It is charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety in hospitals, ambulatory surgical facilities, birthing centers and certain abortion providers. Its role is non-regulatory and non-punitive.

The Authority initiated statewide mandatory reporting in June 2004, making Pennsylvania the only state in the nation to require the reporting not only of Serious Events but also near misses. All reports are confidential and non-discoverable, and they do not include any patient or provider names.

A Successful Beginning - A Plan to Achieve

Since its inception, the Patient Safety Authority has primarily been focused on development and implementation of the Pennsylvania Patient Safety Reporting System (PA-PSRS), review and analysis of reports submitted through PA-PSRS, and the distribution of guidance primarily through the Patient Safety Advisory.

The Patient Safety Authority made tremendous strides in fulfilling its mission and in the short time of its existence, has been recognized as a leader in patient safety data collection, analysis and guidance.

In 2007, the Patient Safety Authority Board determined that the Authority should do more to advance patient safety in Pennsylvania. The Board embarked on a strategic planning exercise. They listened to stakeholders, experts and staff. The outcome of this exercise is a strategic plan that the Board believes will guide the Authority's activities for the next several years.

The Strategic Plan organizes the Authority's objectives and priorities into a series of initiatives. These initiatives will be implemented over several years and will be allocated appropriate funding. The 11 initiatives follow:

-- Initiative A: Educate Executive Management and Boards of Trustees

-- Initiative B: Infection Awareness and Reduction

-- Initiative C: Patient Safety Knowledge Exchange (PasSKEy)

-- Initiative D: Improve Reporting Consistency and Recommendations

-- Initiative E: Increase Effectiveness through Extended Presence

-- Initiative F: Governor's Office of Healthcare Reform (GOHCR) Collaboration

-- Initiative G: Data Collaboration

-- Initiative H: Patient Safety Methods Training

-- Initiative I: Nursing Home Data Analysis

-- Initiative J: PA-PSRS System Enhancements

-- Initiative K: Maintain Success of Patient Safety Advisory

Implementing the strategic plan initiatives has been a priority in the second half of 2007. For example, The Authority is working with the Hospital and HealthSystem Association of Pennsylvania (HAP) and the American Hospital Association (AHA) to develop/adopt a curriculum for Pennsylvania's CEOs and boards of trustees to understand their role in patient safety. Nursing home data and HAI prevention initiatives are being addressed through the implementation of Act 52. The Authority also met with several Patient Safety Officers throughout the year to present ideas and obtain feedback. These efforts support another strategic plan initiative regarding development of the Pennsylvania Knowledge Exchange (PasSKEy). This electronic confidential forum would allow Patient Safety Officers to discuss problems and share written solutions in their facilities freely with one another to improve patient safety. Also geared toward helping facilities improve patient safety, the Authority plans to hire Patient Safety Liaisons to go into facilities and help them implement better system processes. The PSLs would also obtain valuable feedback from the facilities to learn how the Authority can help them further. The Authority will also hire a Director of Education Programs. For more information on the Authority's Strategic Plan, go to page 12 of this annual report.

Reducing Infections through Act 52

In July, Act 52 of 2007 gave the Authority responsibilities related to the prevention of healthcare-associated infections (HAI) in Pennsylvania. Specifically, the Act calls for the Authority to work with the Department of Health and the Pennsylvania Healthcare Cost Containment Council to collect infection data through the Centers for Disease Control and Prevention reporting system. To eliminate duplicate reporting, the Authority modified the CDC system to satisfy the reporting requirements for hospitals. Hospitals began reporting through NHSN on February 14, 2008.

The Act also requires the Authority to collect HAI reports from the approximately 800 Pennsylvania nursing homes. The Authority is working with the Department of Health to identify what information will be collected and the collection systems and processes. It is anticipated that the nursing homes will be reporting infections by the end of 2008. The Authority has also been charged with analyzing the infection data for Act 13 facilities and nursing homes and making the Patient Safety Advisories available to all.

In accordance with Act 52, the Authority established a panel of HAI experts to provide guidance for the effort to combat infections in Pennsylvania's hospitals and nursing homes. While developed and managed by the Authority, the Advisory panel is available to counsel all state agencies with responsibilities related to Act 52. More information about Act 52 and the Advisory Panel can be found on page 15.

Data Collection - Patterns and Trends in Reports Collecting and analyzing reports of Serious Events and Incidents are vital components to the Authority's educational initiatives. The reports are submitted through the Pennsylvania Patient Safety Reporting System, known as PA-PSRS.

The data was submitted by Pennsylvania's 511 hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities. These facilities submitted 211,983 reports; 7,277 were classified as Serious Events (adverse events with patient harm) and 204,706 classified as Incidents (near misses and events that reached the patient but did not cause harm) into PA-PSRS in 2007. Almost 97% of the events in 2007 were classified as Incidents. The Authority believes that robust submission of Incident reports generally indicates a positive culture of safety within a facility that reflects open communication and attention to patient safety efforts. In Figure 1, report volume in 2007 showed an increase of 16,151 reports over 2006, with an increase in both Incidents (8%) and Serious Events (5%).

[See Figure 6 on page 28 of the Annual Report]

When reporting an event to the Authority, a facility uses a classification system or "taxonomy" to characterize the occurrence they are reporting. A facility classifies a report by identifying what PA-PSRS defines as the "Event Type." The Event Type essentially answers the most basic question about an occurrence: "What happened?" While there is considerable detail within the taxonomy, at its most basic level, the PA-PSRS classification contains nine Event Types.

[See Figure 14 on page 36 of the Annual Report]

Other highlights of data submitted through PA-PSRS during the calendar year 2007 are:

-- 512 hospitals, ambulatory surgical facilities and birthing centers were subject to Act 13 reporting requirements. They submitted 211,983 reports of Serious Events and Incidents through PA-PSRS, an increase of 16,151 reports or 13% from 2006.

-- Almost ninety-seven (96.6) percent of all reports were Incidents, in which the patient was not harmed; approximately 3.4% of all reports were Serious Events, which indicates that the patient received some level of harm, ranging from minor, temporary harm to death. Incident reports increased 8% over last

year. Serious Event reports increased 5%.

-- Reports from hospitals accounted for 98.7% of all reports submitted.

-- Women patients were more involved in reports (54.4%) than men (45.6%). Women are more likely to use the healthcare system during childbearing years. They also have a longer life expectancy than men and therefore are using the health system more.

-- Adverse Drug Reactions for women were 63%, while for men they were 37%.

-- Children and adolescent (aged 21 and younger) reports increased by 3.3% in 2007.

-- Patient Falls accounted for 17% of all reports, a decrease from 21% in 2006.

-- While Complications related to Procedures, Treatments or Tests accounted for just 15% of overall reports, they accounted for 44% of reports in which a patient was harmed and 59% of all reports of events resulting in or contributing to a patient's death.

-- Elderly reports have maintained a consistent pattern. More than half of all reports (52.7%) involve elderly (age 65 and over) patients, down slightly from 2006 (53.1%). Elderly patients accounted for 61.2% of Falls in 2007, a drop from 2006 (62.4%). Elderly patients accounted for 73.1% of reports related to Skin Integrity in 2006, this figure increased slightly in 2007 to (73.5%).

-- Medication Errors accounted for 22% of all reports (slight decrease from 2006), and they represented only 1% of all Serious Events. Although most Medication Errors involve adults, Medication Errors involving children and adolescents were more likely to result in patient harm.

The complete data section can be found on page 21 of the annual report.

Variation in Report Volume

The volume of reports, after adjusting for volume of care delivered in different facilities, submitted to PA-PSRS varies significantly by facility. Table 1 shows the range of report volumes from hospitals by quartile. A small number of hospitals submitted no reports in 2007. Differences among hospital types does not explain the variations. Hospitals of all sizes, specialty and location fall into each of the quadrants shown below.

[See Table 6 on page 32 of the Annual Report]

The Authority believes the disparate reporting rates are due to several factors including differences in Act 13 interpretations, facility case mix, varying levels of facility cultures of safety, and potential over-reporting and under-reporting. The Authority will take steps to balance the reporting rates and has included this effort in the Strategic Plan. These steps will include discussions with the Department of Health to clarify Act 13 definitions and a special project aimed at determining the characteristics of high-reporting facilities. Appropriate educational efforts will follow these activities. (Additional discussion of this issue is provided on page 21 of the annual report.)

Providing Guidance

The Authority's professional staff of clinical analysts reviews and analyzes all Serious Event and Incident reports. Their research, strengthened by extensive literature review, is published in the Patient Safety Advisory, a quarterly publication directed primarily to healthcare professionals and facility administrators. Advisory articles provide clinical guidance about process improvements facilities can adopt to improve patient safety and reduce potential patient harm. To date, more than 140 scholarly articles about specific events submitted through PA-PSRS have been published.

In 2007, through legislation signed into law as Act 52, the Authority was charged with collecting and analyzing healthcare-associated infection (HAI) reports from Pennsylvania's nursing homes as well as hospitals under Act 13. The Act also calls for the Authority to offer healthcare-associated infection prevention guidance through Advisory articles and educate nursing homes and other healthcare facilities.

In a 2007 annual survey, 96% of responding hospitals and ambulatory surgical facilities found information in the Patient Safety Advisories useful and relevant, which may explain why the Advisories' reach extends beyond Pennsylvania's borders. Many states from across the country have requested information and resources from the Advisories and many subscribe to the Authority's mailing list to receive them regularly. If you would like to subscribe to the Patient Safety Authority's Advisory go to and click on Advisories.

Research findings highlighted through Patient Safety Advisory articles include issues that:

-- Raised awareness of frequent near miss and actual events of wrong-site surgery in Pennsylvania, while acknowledging that it is a national problem as well. Site visits with volunteer facilities helped us to focus on procedures and behaviors that may reduce the risk of wrong-site surgery. Continued follow up will occur to maintain awareness of wrong-site surgery risks and to develop additional guidance.

-- Highlighted the frequency of reports related to methicillin-resistant Staphylococcus aureas (MRSA), including 14 deaths. In 90% of the cases, a MRSA screening was not noted as having been done when the patient was admitted to the facility. In about 13% of reports where MRSA was found upon admission, the information about the infection was not communicated to other healthcare workers. Consumer tips for how the patient can help protect themselves against MRSA were included with this Advisory and have been distributed through other means.

-- Assessed volunteer users of electronic pharmacy systems in Pennsylvania. The study raised awareness that the pharmacy computer systems were not detecting all unsafe drug orders. The Authority encouraged all Pennsylvania facilities to test their systems to ensure all potentially harmful medication errors are caught.

-- Focused attention on the increased risks of anesthesia complications for patients with obstructive sleep apnea (OSA). OSA is a common sleep disorder that causes recurrent episodes of complete and partial airway collapse during sleep, resulting in the failure to breathe properly. Approximately 80-90% of patients with OSA are undiagnosed, but incorporating OSA into pre-surgical screening gives clinicians an opportunity to take steps to reduce anesthesia complications for these patients. Over 250 reports show OSA as a contributing factor for anesthesia complications. About 20% are considered Serious Events, including three deaths.

-- Continued focus on frequency of medication errors highlighting unclear and confusing labeling and packaging, as well as look-alike or sound-alike drug names as potential causes. The Authority offered guidance on how to minimize the risk by using technology such as bar coding and automated dispensing technology; requiring staff to double check the dose before administering; and monitoring patients closely before discharge.

The Authority's research findings are disseminated widely through the Patient Safety Advisories. The importance of distributing the Advisories to all appropriate healthcare facility staff cannot be emphasized enough so that the facility can benefit fully from the "lessons learned." Several of Pennsylvania's Patient Safety Officers have commented on the usefulness of Patient Safety Advisories, and understand the importance of sharing the information with staff. Examples appear below.

The PSA has provided our organization with valuable information through their Advisory publications. They are widely distributed and used throughout our Health System. The Authority has also done a great deal to advance consistency in reporting of information, as well as insight into the frequency of safety Incidents and Serious Events as a whole. With the open discussion at our Patient Safety Committee meetings, many topics once "hidden" are now seeing the light of day. I believe we are a more well-informed organization - with heightened awareness of the events affecting us in our delivery of health care.

Joan Silver, BSW, RN, MS, CPHQ

Vice President, Organizational Quality

Pinnacle Health System

The Patient Safety Authority has greatly elevated our awareness of patient safety in our hospital. The Patient Safety Advisories, in particular, are a useful resource tool. The information is disseminated to the appropriate department managers and process improvements have been implemented as a result of the Authorities recommendations. We continue to strive to make safety a priority every day in everything we do at Reading Hospital.

Roseann Castanaro

Risk Manager/Patient Safety Officer

Reading Hospital & Medical Center

We have found the Patient Safety Advisories beneficial and we share them with the management staff and the physicians (Patient Safety Committee) to share the knowledge gleaned from the Advisories. Statewide trends are beneficial - seeing value come from our work is beneficial, we just don't enter data - we see feedback as a result of all facilities participating.

Diane Cooper

Patient Safety Officer

Monongahela Valley Hospital

The value of the Authority and PA-PSRS allows our facility to keep its fingers on the pulse of patient safety. The Advisories are keeping pace with current topics, and in many areas, striving to serve as a proactive source from retrospective data analysis. The ability to review the PA-PSRS data assists our facility to implement effective changes efficiently.

Gene Mushak

Patient Safety Officer

Allied Services Rehabilitation Hospital

The Patient Safety Advisories are a valuable educational tool. When received, they are shared with members of our Patient Safety Committee, management staff, medical staff and employees who provide direct care to our patients. We have made the Patient Safety Advisory website available to our employees via our Intranet.

Brenda Rusnak

Patient Safety Officer

Jefferson Regional Medical Center

I use the PSA for in-service and [distribute] Advisories to all staff for review. I recently used the Advisory on early identification of MRSA to support a capital equipment request for rapid turn-a-round culture lab equipment. This particular Advisory summed the need up concisely and was very helpful in supporting our request.

Jo Evans, RN BSN

Director Quality/Risk Management

Heart of Lancaster Regional Medical Center

Education, Outreach and Collaboration

Education and Training

FMEA Training

In May and June 2007, the Authority offered a two-day workshop on Failure Mode and Effects Analysis (FMEA) for all PA-PSRS users and other attendees. The hands-on workshop allowed Patient Safety Officers to mitigate potential risks and develop control strategies where risk is present within their own healthcare facility.

PA-PSRS System Training

In May, a new user training session was held in conjunction with the FMEA training in Gettysburg and in December a webinar was offered for the first time with attendance at full capacity. The Authority also offers online training at

Wrong-Site Surgery Study

In June, the Authority held a press conference raising the awareness of wrong-site surgery, not only in Pennsylvania, but nationally as well. In September, the Authority visited several facilities to study why some facilities were better than others at preventing wrong-site surgeries. The wrong-site surgery study will continue as more information is obtained from facilities. For the complete Patient Safety Advisory article on the study and follow up go to the June 2007 and December 2007 Patient Safety Advisories at

Patient Safety Advisory Toolkits

The Authority also developed an educational toolkit with each Advisory as an additional resource for facilities to improve patient safety. The toolkits have covered topics such as preventing wrong-site surgery, decreasing the risk of medication errors in verbal orders, reducing the likelihood of skin tears and increasing hospital bed safety.

Outreach to Facilities and Providers

Authority staff and board members participated in numerous hospital-based educational programs throughout the year by making presentations to clinical staff about patient safety. Most audiences included physicians, nurses, pharmacists, other healthcare workers and administrators.

PSA Pharmacy Survey Project

In January 2007, 32 PA-PSRS facilities engaged in a statewide field test of hospital pharmacy systems. The study raised awareness that the pharmacy computer systems were not detecting all unsafe drug orders. Participating facilities received a report at the end of the survey that gave their facility's results along with the de-identified statewide results. The aggregate results were published in the March 2007 Supplemental Patient Safety Advisory and presented at the Patient Safety Authority board meeting held in March during 2007 National Patient Safety Week.

Colonoscopy Perforation Project

The Authority continued its study on the frequency of routine colonoscopy perforations and the risks associated with them. This study aims to answer questions about the rate at which colonoscopy-associated perforations occur, the risk factors for colonoscopy-associated perforation, and best practices for controlling modifiable risk factors. The Authority's PA-PSRS clinical director is working with a physician work group to determine the answers to these questions through data submitted to the Authority.

Health Care Improvement Foundation (HCIF) of the Delaware Valley Healthcare Council

The Authority has provided the Healthcare Improvement Foundation (HCIF) with de-identified data on wrong-site surgery and patient falls from hospitals in Southeastern Pennsylvania. The information will allow HCIF to prioritize patient safety initiatives based upon these areas that need improvement.

Consumer Tips Sheets Involve Patients

Although the primary work of the Authority is focused specifically on healthcare facilities it is obvious that patients are at the center of all patient safety activities. The Authority is committed to providing individual citizens, the consumers of healthcare, with information that can impact their healthcare and steps they can take to assure they receive quality care.

In 2007, the Patient Safety Authority developed and distributed consumer tips sheets with selected Advisory articles. These tips provide patients with more knowledge about specific healthcare topics. They include: medication errors, wrong-site surgery, color-coded wristbands, falls, MRSA, the risks for sleep apnea patients and the importance of knowing your medical history. There are many opportunities for patients and their loved ones to become involved in their healthcare, from making decisions about treatment protocols to assuring that providers are adhering to safe practices such as hand washing and verifying medications before administering them. The consumer tips sheets are another educational tool the Authority uses to reach out to the facilities and their patients. The Authority also continued to distribute the Speak Up(TM) brochure developed by the Joint Commission to give patients the information they need to "speak up" and ask their healthcare providers questions so they can be active participants in their healthcare.

To access the consumer tips sheets or other consumer-related information go to and click on "Tips for Consumers."

Anonymous Report Brochure

The Authority received only one Anonymous Report in 2007. The Anonymous Report is an important vehicle for comprehensive event reporting. In order to promote the Anonymous Report alternative, the Authority developed an Anonymous Report brochure this year for Patient Safety Officers to display prominently in their facilities for staff to access. The form is for healthcare workers to complete if they feel a patient in their facility suffered an unanticipated injury involving the clinical care of a patient. However, the healthcare worker's first obligation is to report the event internally according to their facility's patient safety plan. If the healthcare worker is not satisfied with the manner in which the report was handled by the facility, then they are asked to consider filing an Anonymous Report with the Patient Safety Authority. A report form is provided in the brochure.

It is a goal of the Authority's that these matters are handled properly within the healthcare facility so that Anonymous Reports are not necessary. Every healthcare worker should feel empowered to speak if he or she feels a patient has not been cared for properly. Healthcare management and supervisors should communicate openly with their staff so that staff feels their concerns are heard and dealt with accordingly.

The Authority believes open communication among hospital staff and patients is an integral component for a successful culture of safety in any facility.

For the complete annual report, more information about the Authority and access to issues of the Patient Safety Advisory, go to the Authority's website,

SOURCE Pennsylvania Patient Safety Authority