The Patient Safety Authority issued its Annual Report for 2006 with survey information indicating that change is occurring as a result of guidance issued in Patient Safety Advisories, but the survey also indicated more work is needed to improve patient safety and reduce preventable medical errors in Pennsylvania's healthcare facilities.

"The patient safety officers in Pennsylvania's healthcare facilities, responding to a statewide survey, indicated that they implemented over 500 changes in their facilities as a result of the Advisory guidance and PSOs collectively gave marks of 97 percent or better for the Advisories' usefulness, relevance and readability," said Dr. Ana Pujols-McKee, chair of the Patient Safety Authority Board of Directors. "However, the survey also shows that facilities find there is room for improvement in increasing the culture of safety within their institutions and thus reducing preventable medical errors."

McKee added that an important component of increasing patient safety in healthcare facilities is to continue developing cultures of safety which means leadership must keep encouraging full and open disclosure to patients, and the acknowledgement of mistakes while implementing procedures to prevent future errors.

Under Act 13 of 2002, all hospitals, birthing centers and ambulatory surgical facilities (certain abortion facilities were added in 2007) must submit reports of Serious Events (actual adverse events) and Incidents (near misses). In the calendar year of 2006, facilities submitted a total of 195,832 reports, an increase of nearly 26,000 reports over 2005. Approximately 96.5% of these reports were Incidents that did not result in patient harm. The remaining 3.5% were Serious Events, in which the patient received some level of harm, ranging from minor, temporary harm to death.

The Authority issues quarterly Patient Safety Advisories to provide guidance to facilities about steps they can take to promote patient safety and reduce the potential for medical error. The Advisory articles have generated considerable attention, with the Authority recognized in October 2006 with the prestigious John M. Eisenberg award in large part as a result of the Advisories' usefulness. National medical publications, as well as The Wall Street Journal, have written articles derived from the Patient Safety Advisory and PA-PSRS data.

More than 40 articles based on specific events submitted through PA-PSRS were published in 2006. Research findings and guidance communicated through Patient Safety Advisories are highlighted below:

-- In the March 2006 issue, one article raised concerns regarding the administration and monitoring of a popular sedation drug call Propofol (PRO-pa-fall). Over 100 reports cited the drug in question, including four reports involving the patient's death. Other articles in this issue detail infection risks involving manufacturer's representatives, contaminated surgical instruments and look-alike drug packaging.

-- The June 2006 issue highlighted data showing that verbal drug orders are often misunderstood and lead to errors. Facilities were given a toolkit to implement which includes a read-back procedure to help reduce the likelihood of error. Other articles in this issue describe risks associated with hydrofluoric acid exposure, procedures to help reduce the risks of transplant tissue contamination, problems associated with the painkiller Demerol and trends in adverse event reporting among behavioral health hospitals.

-- The Supplementary August issue updated facilities on the efforts made by hospitals to standardize color-coded wristbands in Pennsylvania. In 2005, a patient nearly died in a Pennsylvania hospital due to confusion caused by the color of the wristband. Since then the Authority and a group of hospitals in Pennsylvania have gained national recognition for their efforts in reducing the risks associated with color-coded wristbands.

-- In the September 2006 issue, an article raised awareness about the frequency of skin tears among older patients. Older patients (age 65 and older) account for 88 percent of all skin tears reported. Clinical guidance to prevent the painful unsightly wounds was given. Other articles in this issue show risks associated with MRI-incompatible sandbags, taking a closer look at medication errors and why they happen, the dangers associated with the high-alert drug epinephrine and information on how to prevent bed sores.

-- In the December 2006 issue, an article informed orthopedic surgeons about the rare but deadly hip surgery complication known as Bone Cement Implantation Syndrome (BCIS). In five out of six reports of BCIS received, the patient died from cardiac arrest associated with the implantation of the new hip prosthesis. Other articles in this issue show the dangers of hospital bed entrapment, the prevalence of perforations of the colon during colonoscopy, risks associated with feeding tube placement when outdated methods are used and the dangers associated with the high-alert drug Heparin.

In 2006, educational toolkits were added to Advisories to help healthcare facilities implement the guidance offered in the Patient Safety Advisory. The toolkits include slideshows for educating frontline caregivers, posters and other materials for raising awareness. Facilities in Pennsylvania and nationally have used the toolkits to improve patient safety in their facilities. The Authority also sponsored a two-day Root Cause Analysis conference to help facilities get to the "root cause" of events and make the necessary process changes to prevent errors from occurring again.

"In the last year, the Authority has focused more on its educational initiatives for facilities," said Michael Doering, interim executive director of the Patient Safety Authority. "The toolkits and educational workshops sponsored by the Authority will continue, along with more initiatives all geared toward helping facilities implement strategies that will improve patient safety in Pennsylvania's healthcare facilities."

Doering added that while the educational efforts have increased and facilities have implemented changes, the work must continue because reports continue to increase.

"The number of reports increased by 26,000 in 2006," said Doering. "While reported events with harm have decreased slightly, the number of near misses has increased. On the one hand, we're pleased with these numbers because it means healthcare facilities are being more vigilant in reporting potential errors, but if appropriate changes aren't made, the threat still exists for harmful errors to occur."

A total of 464 healthcare facilities were subject to Act 13 reporting requirements in 2006. Hospitals accounted for 98.7% of all reports submitted. The most frequently reported events were errors related to procedures, treatments and tests and medication errors (47%). However, complications related to procedures, treatments and tests resulted in more Serious Events or events that caused harm (42%), even though there were only 14% of them reported.

The Patient Safety Authority survey mentioned above was distributed to all Patient Safety Officers (PSOs) from Pennsylvania hospitals, ambulatory surgical facilities and birthing centers in November 2006. The Authority received responses from 186 out of 419 PSOs of record at the time of the survey, representing a response rate of 44%. For complete survey results go to pages 13-18 of the Annual Report.

-- An Executive Summary of the Annual Report (PDF)

For the complete Annual Report, go to the Authority website at www.psa.state.pa.us, or click on the following link.