Pennsylvania Patient Safety Authority Issues Annual Report for 2010
The Authority highlights the success of its Patient Safety Liaison Program and blood specimen mislabeling collaborative as well as the reduction of healthcare-associated infections in hospitals and nursing homes
HARRISBURG, Pa., April 28, 2011 /PRNewswire-USNewswire/ — The Pennsylvania Patient Safety Authority issued its 2010 Annual Report highlighting its Patient Safety Liaison (PSL) program and educational activities as well as reductions in healthcare-associated infections (HAIs) in hospitals and nursing homes.
The PSL program began in August 2008 and reached its full complement of six in May 2010. Overseen by the Authority’s Director of Educational Programs, each PSL has between 65-100 healthcare facilities that they meet with on a regular basis to ensure the Patient Safety Officers (PSOs) are aware of the numerous educational resources available to them from the Authority and other patient safety leaders.
“The Authority’s Patient Safety Liaison program is the first of its kind in the nation,” Dr. Stanton Smullens, acting chair of the Pennsylvania Patient Safety Authority, said. “Since 2008, the PSL program has grown so that every hospital, ambulatory surgical facility, abortion facility and birthing center reporting events has someone they can consult with on an individual basis about patient safety issues.”
Smullens added that one PSO speaking about the PSL program called it a “game changer.” In 2010, more than 1,700 PSOs and other healthcare professionals were educated through the PSLs and Authority staff on various patient safety topics such as wrong-site surgery and HAIs.
Smullens said educational collaboratives are another important part of the Authority’s strategic plan to reduce adverse events and improve patient safety. From August 2009 through October 2010, the Authority sponsored a multihospital blood specimen mislabeling collaborative in the Northeast. The Authority worked with hospitals to measure blood specimen labeling error rates, offer educational programs to understand how errors occur and risk reduction strategies to decrease the likelihood of another error, document hospital-specific interventions to reduce the labeling error rate and measure the outcome of the interventions.
“At the end of the collaborative, there was a thirty-seven percent aggregate statistically significant decrease in specimen labeling errors,” Smullens said. “Collaboratives allow facilities to work toward reducing adverse events and near misses together while formulating best practices.”
Smullens added the Authority’s scope of activities for the collaborative included: educating participants with specific courses geared toward a Just Culture(TM), providing participants with data collection and event investigation tools, providing ongoing aggregate data analysis for participants, being available for participant mentoring and coaching and facilitating interhospital communication and collaboration to reduce blood specimen labeling errors.
Other collaborations sponsored by the Authority include topics such as: wrong-site surgery, HAIs and falls.
For more information about the PSL program, collaboratives and comments from PSOs, go to Section IV of the Authority’s Annual Report at www.patientsafetyauthority.org. For more information about the blood specimen labeling collaborative go to the same website and click on the preview Pennsylvania Patient Safety Advisory article “Blood Specimen Labeling” under the “Upcoming Articles” section.
Smullens said the Annual Report also highlights the healthcare-associated infection data collected from hospitals, ambulatory surgical facilities and nursing homes.
“The overall rate of infections reported by hospitals decreased by approximately six percent from 2009 to 2010,” Smullens said. “Specifically, catheter-associated urinary tract infections or CAUTI decreased by twenty-six percent, central-line associated bloodstream infections or CLABSI by forty-four percent and ventilator-associated pneumonia by twenty-seven percent.”
In 2007, a new law was passed making it mandatory for hospitals to report HAIs through the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). The Authority has access to the reports in NHSN and analyzes them for its educational purposes. The Pennsylvania Department of Health and the Pennsylvania Healthcare Cost Containment Council (PHC4) share access of this data.
Smullens added that nursing homes reported 27,898 HAI events to the Authority in 2010. Report declines were seen in all five care areas that include: dementia unit, mixed unit, nursing unit, skilled nursing/short-term rehabilitation unit and ventilator dependent unit. Nursing homes began reporting HAIs in June 2009.
“Over seven hundred nursing homes reported healthcare-associated infections to the Authority in 2010,” Smullens said. “Nursing homes reported fewer urinary tract infections by fourteen percent in residents without a catheter and fifteen percent less in residents with catheters. There were 18 percent fewer skin and soft tissue infection reports compared to 2009 data.”
Smullens added that nursing home facilities are eager to obtain any educational materials the Authority provides including Pennsylvania Patient Safety Advisory articles and educational webinars. Topics have included: methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infections (CDI). In October, the Authority provided nursing homes, hospitals and ambulatory surgical facilities with posters to raise awareness of CDI due to increases in the number of events, particularly in nursing homes.
For more information about events data and healthcare-associated infection data in hospitals and nursing homes go to Sections II and III of the 2010 Annual Report at www.patientsafetyauthority.org.
Other Highlights of the Authority’s 2010 Annual Report include:
2010 Annual User Survey Results
Facilities also continue to make changes to improve patient safety according to the Authority’s annual user survey. In December 2010, 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 [98%], relevant [98%], readable [100%], high in scientific quality [100%] and high in educational value [98%],” Smullens said. “We also know that over sixty-three percent of PSOs surveyed have made or plan to make changes in their facility based upon the guidance presented in the articles.”
For more information on the annual user survey, go to Section VI of the 2010 Annual Report.
Pennsylvania Patient Safety Advisory Subscriptions Go Global
The Pennsylvania Patient Safety Authority distributes its Pennsylvania Patient Safety Advisory to more than 5,000 program affiliates (i.e. acute healthcare facilities, nursing homes, board and panel members in Pennsylvania) as of December 31, 2010. About 25 percent of these recipients are PSOs in acute healthcare facilities or infection prevention designees in nursing homes. The remaining majority constitutes other recipients with the Authority’s reporting facilities or patient safety programs.
“The Authority switched to a new e-mail distribution system in July and has seen its general subscriber list continue to grow,” Smullens said. “Subscribers include individuals from every state, fifty-six percent from Pennsylvania, and from twenty-eight other countries.”
For more information about the Pennsylvania Patient Safety Advisory and subscribers, go to Section VII of the 2010 Annual Report.
Signs of Safety Improvement and Patient Safety Authority Product Value Analysis
For those working in patient safety, a variety of sources are available that offer evidence about whether the delivery of healthcare is becoming safer. One significant area of success found in Pennsylvania is a reduction in malpractice claims since the Medical Care Availability and Reduction of Error Act of 2002 (MCare)–the Authority’s authorizing legislation–was signed into law.
“Since the MCare Act, payouts from the liability fund have dropped by almost sixty percent,” Smullens said. “Some of this decline is attributed to MCare’s tort reform provisions, such as the requirement for certificates of merit, a reduction of MCare coverage limits, and the requirement that malpractice actions be brought in the county where cause of action occurred. But some may be attributed to the healthcare facilities’ progress in improving patient safety.”
For a complete analysis of the signs of safety improvement in Pennsylvania’s healthcare community and a thorough product value analysis of the Pennsylvania Patient Safety Authority go to Section VIII of the 2010 Annual Report.
An Executive Summary of the 2010 Annual Report follows. The complete Annual Report for 2010, as well as additional information about the Patient Safety Authority, is accessible on the Authority’s website www.patientsafetyauthority.org.
The Pennsylvania Patient Safety Authority (the 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 through data collection, identifying problems and recommending solutions that promote patient safety in hospitals, ambulatory surgical facilities, birthing centers and certain abortion providers. In June 2009, the Authority began collecting infection reports from nursing homes. The Authority’s primary functions include data collection, data analysis, guidance, education and training. The Authority’s role is non-regulatory and non-punitive. The Pennsylvania Department of Health is the regulatory agency of the Commonwealth.
The Authority initiated statewide mandatory reporting in June 2004, making Pennsylvania the only state in the nation to require the reporting of Serious Events and Incidents (near misses). With respect to civil law matters, all reports are confidential and nondiscoverable, and they do not include any patient or provider names. In 2007, the legislature added a chapter to the MCare Act that addressed reporting of healthcare-associated infections (HAIs) in Pennsylvania and required infection reporting from nursing homes to the Authority and the Department of Health. The Authority developed a new module in the Pennsylvania Patient Safety Reporting System (PA-PSRS) to collect this data.
This Annual Report focuses on the primary activities, accomplishments and achievements of the Authority in 2010 including enhancement of the Authority’s educational initiatives through the Patient Safety Liaison (PSL) program. The PSLs will help initiate more collaboratives designed to help measure patient safety in facilities and will also help increase our interaction with consumers/patients. In addition, the report focuses on the Authority’s activities to eliminate HAIs in hospitals, ambulatory surgical centers, birthing centers, abortion facilities and nursing homes.
Inquiries from other states as to how the MCare Act and the Authority were developed prompted a background piece for a trade journal. Excerpts from the article are included in this Annual Report. An Advisory article regarding the substantial drop in medical malpractice claims and its potential relationship to patient safety is also included. A value analysis of the Authority’s output is also detailed in Section VIII of this Annual Report.
Aggregate data from 2010 facility reports will be given for report volume, patient demographics and patterns in reports. This information will include updated information from healthcare-associated infection data collected from Pennsylvania nursing homes. Samples of information provided in the Pennsylvania Patient Safety Advisories and the latest subscription rates which include countries around the world are also included in this Annual Report. Results of our annual survey of Patient Safety Officers are also highlighted in Section VI.
For copies of the 2010 Annual Report, go to www.patientsafetyauthority.org.
Patient Safety Authority Receives Cheers Award
In October 2010, the Pennsylvania Patient Safety Authority received a Cheers Award from the Institute for Safe Medication Practices (ISMP) for its educational efforts in preventing medication errors and adverse drug events. An awards ceremony took place in December in Anaheim, California. ISMP honored six individuals, organizations and companies that have set a “superlative standard of excellence for others to follow in the prevention of medication errors and adverse drug events.”
The Authority’s Strategic Plan Drives Activities
In 2007, the Patient Safety Authority Board decided that the Authority should do more to educate Pennsylvania providers about patient safety and should increase collaboration with other entities in order to improve patient safety. After a strategic planning exercise at a board retreat, objectives were developed for the Authority’s next steps for improving patient safety. The board approved the 11 initiatives unanimously. Much of the Authority’s work highlighted in this Annual Report is a result of the board’s strategic focus.
Most of what the Authority presented in the strategic plan has been accomplished. However, the Authority has not made much traction with respect to an initiative calling for more standardization in reporting. While reporting has increased significantly since development of the strategic plan, significant differences in facility reporting rates persist. The Authority produced a set of reporting principles which could have blunted the reporting discrepancy somewhat, but it has not been approved by the Department of Health and has not been implemented. The Authority identified and communicated with 50 facilities that appeared to be the lowest reporters. This exercise greatly increased the number of reports coming from these facilities.
Quantifying overall improvements in patient safety in Pennsylvania remains a challenge for the safety field in general, as differences in facility reporting recommend against using the volume of staff-generated reports as a statistically relevant method for measuring overall patient safety. The Authority has taken steps to showcase the value of its efforts including the requirement that collaborative efforts projects include a measurable outcome and development of an analysis of the annual value created by the Authority’s output.
The Authority must continue to review its activities to ensure resources are being used effectively and efficiently. In 2011, the Authority Board will develop a new strategic plan that will provide direction for the next several years. Strategic planning must consider some of the current and potential issues facing patient safety including potential implications of national health care reform, patient and provider relationships under accountable care organizations, and increasing use of pay-for-performance and non-payment for hospital acquired conditions.
The Authority’s Educational Programs
To implement the Strategic Plan the Authority focused its resources on educational programs. These resources were applied to the following six activities:
- Increasing Outreach Efforts for Process Change through the Pennsylvania Patient Safety Liaison Program
- Educating hospital Boards of Trustees and executive management for improved Cultures of Safety
- Expanding Educational Offerings to Encourage Process Change among Healthcare Providers
- Helping Patients and Consumers Engage more in their Healthcare for Patient Safety
- Improving the Authority’s Website for Easier Access to Educational Materials
- Developing PassKey to Give Healthcare Providers a Network of Colleagues to Learn From
These activities are described in more detail below.
Increasing Outreach Efforts through the Pennsylvania Patient Safety Liaison Program
In 2010, the Patient Safety Liaison program became fully staffed. The Director of Educational Programs oversees six Patient Safety Liaisons (PSLs) located within six regions of Pennsylvania. The PSLs act as non-regulatory consultants who visit Pennsylvania’s healthcare facilities to ensure they are aware of the numerous educational resources available to them from the Authority and other patient safety leaders. They provide training and educational materials to facility patient safety officers and discuss each facility’s patient safety program. While acting as a liaison between the Authority and healthcare facilities, the PSL also serves as a liaison between healthcare facilities within the region. The program includes: one PSL in the Northeast, one PSL in the Northwest, one PSL in the South Central region, one PSL in the Southwest, and two PSLs in the Delaware valley (one north and one south). In 2010, the liaisons served approximately 540 facilities in Pennsylvania including hospitals, ambulatory surgery facilities (ASFs), birthing centers and certain abortion facilities. Since the pilot program began with one PSL in August 2008, the program has continued to have success in each region. Much more about the PSL program and its success is discussed in Sections IV and V of this Annual Report.
Patient Safety Training for Executives and Boards of Trustees for Improved Cultures of Safety
In 2010, the Authority and the Hospital and Healthsystem Association of Pennsylvania (HAP) moved beyond the pilot program to educate hospital executives and boards of trustees, begun in 2009, and began putting the pieces in place to train education consultants who will then educate facilities across the state. The education consultants are needed to fully implement the program statewide.
The pilot program to educate executive management and boards of trustees about their role in improving patient safety is an initiative designed to raise awareness and increase responsibility for patient safety by bringing it to the board of trustee level.
The Patient Safety Authority partnered with the Hospital and Healthsystem Association of Pennsylvania (HAP) and the American Hospital Association (AHA) to develop and execute the pilot program. An advisory panel composed of executive leaders and trustees from hospitals and health systems assisted the Authority and HAP in developing our customized program to foster the kind of senior level and board engagement needed for improved patient safety.
For an update on the patient safety training for facility executives and boards of trustees go to page 94 of this Annual Report.
Educating Healthcare Providers for Process Change
The Authority offers numerous education and training programs to Pennsylvania healthcare providers. The live and web-based training and education sessions are free of charge. Some programs are regional and some are facility/system-specific.
In 2010, the Authority educated thousands of healthcare staff on a wide range of patient safety topics that often come from Patient Safety Officers (PSO) or from the PSLs who notice a patient safety issue that needs addressed regionally or statewide. Topics include but are not limited to: Just Culture(TM), human factors, wrong-site surgery, retained foreign bodies, mislabeling specimens, operating room safety, radiation safety, crew resource management and infection control.
A popular course, the Patient Safety Officer Basic Foundation Course, discusses the specifics behind patient safety and Act 13 of 2002 (the MCare Act). In 2010, over 200 healthcare providers attended the course that was offered six times. A second course, Beyond the Basics, is offered for healthcare providers who feel they’ve mastered the basic principles behind the MCare Act. This course teaches the seasoned PSO how to move forward with improving patient safety on a higher level. Topics of this course include but are not limited to Just Culture(TM), Root Cause Analysis (RCA), disclosure of adverse events to patients and TeamSTEPPS(TM). Over 100 healthcare providers attended the two-day program offered three times in 2010. Ninety-eight percent of the attendees surveyed said they learned something new as a result of the program.
To learn more about the specific objectives of these and other educational programs offered by the Authority go to page 86 in this Annual Report.
Helping Consumers Become More Engaged in Their Healthcare
The Authority is committed to providing individual citizens, the consumers of healthcare, with information that can impact their experience in the healthcare arena by giving them tips on how they can receive quality care.
Consumer Tips and Brochures
In 2010, the Patient Safety Authority continued to develop and distribute 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. For a detailed list of the consumer tips and brochure topics, go to page 96 of this Annual Report.
Most recently, the Authority redesigned its consumer web page to make the consumer tips and brochures more easily accessible. Also included on the new consumer site is information from other state agencies responsible for hospital, healthcare provider and nursing home comparisons. These links are easily accessible from the Authority’s new consumer web page, go to www.patientsafetyauthority.org, click on “Patients and Consumers.”
Website Traffic Increases Since Improvements
During 2008 and 2009, the Authority completely redesigned its website that hosts the library of output created by the Authority. During 2010 the Authority continued with enhancements designed to improve the experience of the site’s users. Based on 2010 usage statistics, the traffic on the Authority’s website has experienced a substantial increase with over 60,000 hits per month.
Speakers’ Bureau and Tips Booth
The Authority continues to reach out to the community through its speakers’ bureau and information booth. Throughout 2010, hundreds of presentations were given to a host of healthcare facilities and organizations on a variety of patient safety issues. When possible, the Authority analyzes data from PA-PSRS that is directly related to the facility or organization topic being presented. These presentations offer their audience a first-hand look at what is going on in Pennsylvania’s healthcare facilities and helps provide insight for setting patient safety goals.
The Patient Safety Authority information booth is available for senior expos and health fairs and other healthcare related events. Much of the information encourages the consumer to participate in their healthcare and gives information related to real events happening in Pennsylvania where the patient or family member helped prevent a medical error by asking questions. Please call the Authority at 717-346-0469 for more information about its speakers’ bureau and information booth.
Development and Implementation of PassKey
It is through collaboration and sharing that patient safety can be efficiently improved. During 2010, the Authority developed and implemented the Pennsylvania Patient Safety Knowledge Exchange (PassKey). PassKey is a custom Pennsylvania application that provides Patient Safety Officers in Pennsylvania with a confidential electronic forum to share information, ideas and solutions. Information on the site is provided by PSOs, but maintained by the Authority staff. The Authority encourages facilities to post as much information as possible regarding how they are improving patient safety in their facilities so other facilities can learn from their success stories. PassKey also allows facilities to ask questions and search for answers that may already be provided on the site.
The Pennsylvania Patient Safety Advisory
The flagship product developed by the Authority is the quarterly Pennsylvania Patient Safety Advisory. The Advisory is a reflection of the reports submitted to the Authority through PA-PSRS. Advisory articles address specific patient safety topics and events that occur in Pennsylvania. Articles typically provide an analysis of the problem, deidentified narratives reflecting Pennsylvania reports, and guidance for improvement based on standards and existing literature.
Since June 2004, over 340 Advisory articles have been published. In addition, patient safety toolkits accompany many articles and are posted at the Authority’s website. The toolkits are additional resources that can be used by providers to improve patient safety in their facilities. In a recent annual Authority survey, 63% of the Patient Safety Officers (PSOs) who responded reported making or planning to make changes based upon a Patient Safety Advisory article. Hundreds of process changes were made by facilities in 2010.
The MCare Act calls for healthcare professionals to periodically earn credits in patient safety. The Authority has partnered with the Pennsylvania Medical Society and the Pennsylvania State Nurses Association to provide patient safety credits though quarterly Advisory articles. The partnerships give healthcare professionals the opportunity to earn patient safety credits while keeping up with the latest data submitted by Pennsylvania’s healthcare facilities.
The Authority distributes its Pennsylvania Patient Safety Advisory to more than 5,000 program affiliates (i.e., acute healthcare facilities, nursing homes, boards and panel members in Pennsylvania). About 25% of these recipients are patient safety officers or infection prevention designees. The remaining majority are other recipients affiliated with the Authority’s reporting facilities or patient safety programs (e.g., senior corporate officials, other affiliates of the facilities reporting events to the Authority through PA-PSRS).
In addition, approximately 2,500 others subscribe to the Patient Safety Advisory. Of these, approximately 96% have a United States address and over half of these are from Pennsylvania. The remainder are distributed to recipients in 48 other states. Approximately 100 subscribers represent 29 separate countries.
A more detailed review of the Patient Safety Advisory and condensed versions of selected Advisory articles are included in Section VII of this report.
Participating in Collaboratives to Improve Patient Safety
In line with the strategic plan, the Authority has developed or participated in several collaboratives designed to improve patient safety related to specific events. Collaboration characteristics include:
- Significant number of participating Pennsylvania facilities
- Use of PA-PSRS data, if appropriate
- Measurable outcome
- Authority Patient Safety Liaison and Patient Safety Analyst assigned to each collaborative
Currently, the Authority is participating in six collaboratives in conjunction with over 125 separate Pennsylvania hospitals. The role of the Authority is varied depending on the particular endeavor. The Authority’s role can include:
- Application and use of PA-PSRS data
- Data analysis
- Preparation and distribution of reports
- Team education and training
- Outcome analysis and measurement
- Collaborative management and administration
- Publication of collaborative results through the Patient Safety Advisory
- Development and use of collaborative work sites in PassKey
The six collaborations currently underway include:
- Surgical site infection collaborative with the Three Rivers Chapter of the Association of Professionals in Infection Control (TRAPIC)
- A falls reduction collaborative with the Health Care Improvement Foundation (HCIF)
- Wrong-Site Surgery collaborative with the University of Pittsburgh Medical Center (UPMC)
- Phlebotomy specimen mislabeling collaborative with Northeastern PA Healthcare Facilities
- Reducing central-line associated bloodstream infections with the Hospital and Healthsystem Association of Pennsylvania (HAP) and the Agency for Healthcare Research and Quality (AHRQ)
- Reducing surgical site infections with the Pennsylvania NSQIP (National Surgical Quality Improvement Program) Consortium
One of the collaborative efforts addressed the mislabeling of blood specimens. A short description of that effort follows.
At the same time that nationally recognized credible agencies were pursuing answers to laboratory medicine best practices, the Pennsylvania Patient Safety Authority facilitated a collaborative effort among nine hospitals in northeastern Pennsylvania whose mission was to improve patient safety by decreasing the number of mislabeled blood specimens. This initiative was developed and implemented through a series of workshops that provided education, tools, technical assistance, resources and an interactive forum. The success of this joint collaboration required a moderate level of commitment, funding and cooperation from the senior management and leaders at each participating facility. Project managers from each site worked closely with the Authority’s Patient Safety Liaison who was responsible for coordinating and facilitating this project. Overall, the nine facilities decreased mislabeling specimen errors by 37 percent. One facility decreased mislabeling errors by 84 percent. For more on the phlebotomy mislabeling specimen collaborative go to page 92 of this Annual Report.
Healthcare-Associated Infections Update
Pennsylvania is a national leader in addressing the challenge of reducing and ultimately eliminating healthcare-associated infections (HAIs) to prevent unnecessary illnesses and deaths, and to eliminate the avoidable costs of treating these infections. Act 52 of 2007 amended the Medical Care Availability and Reduction of Error (MCare) Act, with the goal of reducing and eliminating HAIs.
Pennsylvania hospitals have invested substantial effort to comply with the MCare reporting requirements by conducting surveillance for HAIs and reporting them into the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). The Department of Health, the Pennsylvania Healthcare Cost Containment Council, and the Authority share access to this data.
For hospital HAI reporting the Authority’s responsibilities include the following:
- Analyze the infection reports hospitals enter in the CDC’s NHSN system
- Maintain the HAI Advisory Panel for use by Pennsylvania agencies named in Act 52 of 2007
- Provide facilities with guidance on best practices based on this analysis
- Publish the results of this work in the Pennsylvania Patient Safety Advisory
- Develop educational programs and supporting multi-facility collaboratives to encourage cross-institutional learning.
The Department of Health is responsible for publishing final hospital HAI rates and benchmarks. The 2009 data results determined by the DOH forms the baseline for the purpose of benchmarking. Act 52 requires that Pennsylvania hospitals reach a 10% reduction target for the year 2010 onwards, based on the baseline data reported in 2009. The 2010 data presented by the Authority in this report is a first cut and is prepared in aggregate. The Authority does not publish information by individual facilities.
While the rates of HAIs in Pennsylvania hospitals fared well when compared to the national data, and some findings indicated that rates were substantially lower in some categories, this finding must be cautiously interpreted since Pennsylvania facilities are mandated to report through NHSN while in other parts of the country, reporting is voluntary.
Section III of this report presents details regarding HAI events. Some highlights that relate to hospitals include:
- Hospitals reported over 22,000 HAIs to the Authority in 2010.
- The overall rate of infections reported by hospitals decreased by approximately 6% between 2009 and 2010.
- Between 2008 and 2010, hospitals reduced Catheter-Associated Urinary Tract Infections (CAUTI) by 26%, Central-Line Associated Bloodstream Infections (CLABSI) by 44%, and Ventilator-Associated Pneumonia by 27%.
- From hospitals, surgical site infections were the most commonly reported type (26.1%), followed by UTIs (23.2%), gastrointestinal infections (17.3%), BSIs (11%), and pneumonia (10.9%).
In 2010, nursing homes reported their first full year of infection reports. Nursing homes report HAIs to the Authority through the Pennsylvania Patient Safety Reporting System (PA-PSRS), based on a unique list of infections and criteria developed by the Authority and the Department of Health with guidance from the HAI Advisory Panel.
The Authority’s goals for HAI reporting from nursing homes are to:
- Implement the legal requirements of MCare as amended by Act 52 of 2007, by establishing and maintaining the reporting system and publishing data to allow the assessment of HAI prevention efforts in this care setting.
- Provide limited validation of data quality.
- Analyze the data to support Advisory articles, educational programs and the Annual Report.
- Use the data to identify facilities that are successful with their HAI prevention efforts and those that are unsuccessful in implementing best practices and to assist with methods of implementing improvement strategies.
A major focus of the Authority in 2010 was the analysis of the 27,898 HAI events entered into PA-PSRS by Pennsylvania nursing homes. The Authority analysis shows declines in all five care areas that include: dementia unit, mixed unit, nursing unit, skilled nursing/short-term rehabilitation unit and ventilator dependent unit.
Section III of this report presents details regarding HAI events. Some highlights and observations from that section that relate to nursing homes include:
- Approximately 714 nursing homes reported 27,869 HAIs to the Authority in 2010. Infections reported include: Respiratory tract infections (9,929); gastrointestinal infections (8,495), skin and soft tissue infections (5,214) and urinary tract infections (3,883).
- Between 2009 and 2010, nursing homes reduced urinary tract infections by 14% in residents without a catheter and by 15% in residents with catheters.
- In 2010, preliminary rates of skin and soft tissue infections were reduced by 18% compared to 2009.
Section III of this report also identifies the HAI educational programs and collaboratives being pursued by the Authority in the fight to reduce and ultimately eliminate HAIs in healthcare facilities and nursing homes.
Highlights of Data Submitted to the Pennsylvania Patient Safety Authority
Section II of this report presents details regarding the patient safety events (excluding nursing home HAI) submitted through PA-PSRS during 2010. Some highlights include:
- 538 hospitals, ambulatory surgical facilities, abortion facilities and birthing centers submitted 225,624 reports of Serious Events and Incidents to the Authority, a decrease of 1,046 reports from 2009. In 2010, the Authority received 18,802 reports per month on average, a decrease of 0.5% from 2009. The total number of Serious Events and Incidents reported to the Authority since reporting began June 2004 is in excess of 1.3 million.
- Approximately 97% of all reports submitted by these facilities in 2010 were Incidents, or did not cause harm to the patient. Approximately 3% of all reports were submitted as Serious Events, meaning the patient received some level of unanticipated injury ranging from minor, temporary harm to death. Despite several months where this percentage rose to 4% or greater, there appears to be a downward trend in the percentage of Serious Events among reports submitted to the Authority during the last three years.
- The number of Incident reports averaged 18,176 per month, a decrease of 0.1% from 2009. Serious Event reports averaged 626 per month, a 9.2% decrease from the previous year. Most of the decrease of Serious Event submissions can be attributed to a 39% drop in Skin Integrity (pressure ulcers) Serious Event reports and a 13% decrease in Falls from 2009.
- Reports from hospitals accounted for 85% of all reports submitted. Nursing homes submitted 13.2% of the overall total. Among acute-level facilities (non-nursing homes), hospital’s account for 98% of all reports submitted.
- Ambulatory surgical facilities submitted 13.2 reports per facility in 2010 compared to 12.2 reports per facility in 2009 and 11.8 reports per facility in 2008.
- Statewide, the most frequently reported events in hospitals involved Errors related to Procedures/Treatments/Tests (22%) and Medication Errors (20%) totaling 42% of all reports submitted.
- Reports of Medication Errors decreased overall by 8% from 48,881 reports submitted in 2009 to 45,034 reports submitted in 2010. Approximately 98% of these reports were Incidents or near misses.
- While Errors related to Procedure/Treatment/Test were the event type most frequently reported through PA-PSRS, they were not the event type most frequently associated with patient harm. The event type Complications of Procedures/Treatments/Tests accounted for just 13% of all submitted reports, but totaled 46% of all Serious Event reports and 60% of all reports of events resulting in or contributing to the patient’s death; meaning this event type is significantly associated with harm to the patient. Conversely, while Medication Errors comprise 20% of reports in 2010, they only accounted for 4% of events involving harm and 2% of events contributing to or resulting in death.
- Reports on perinatal patients (those aged 20 days or younger) increased 5.2% compared to 2009. Four percent of all perinatal reports were classified as Serious Events, higher than the overall rate of Serious Events reporting for 2010 (3.32%).
- Reports on patients over age 65 continued to show decreases as in previous years. In 2004 and 2005, older patients accounted for 64% of Falls. This figure declined to 56.2% in 2010. Also, Skin Integrity reports (pressure ulcers) among older patients dropped to 70.6% in 2010 from 71.2% in 2009. More than half of all reports (51.8%) in 2009 involved patients 65 and older; this figure dropped to 48.3% in 2010.
- The Authority expects to be able to measure more effectively patient safety improvement in Pennsylvania healthcare facilities through more collaboratives. Ongoing collaborative topics include wrong-site surgery, falls, surgical site infections and central-line associated blood stream infections.
SOURCE Pennsylvania Patient Safety Authority