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Safety agency watches for trends to protect Pa. patients

Cases like these come to the attention of Pennsylvania’s Patient Safety Authority:

A nursing student accidentally injects oral medication into a 14-month-old baby with leukemia.

A patient loses his vision during cataract surgery from an infection caused by poor hospital sterilization.

A person undergoing surgery has an incision made on the wrong finger.

Medical facilities report about 8,000 medical mistakes annually to the Pennsylvania Patient Safety Authority, the state agency charged with reducing them.

“Our responsibility is to receive these reports, do the analysis and do whatever training and education we can do to reduce patient-safety events in Pennsylvania,” said Mike Doering, executive director.

Though hospitals have systems to record incidents, the authority can examine information statewide to recognize trends, according to Dr. Robert Keenan, the chief quality officer for Allegheny General and West Penn hospitals.

“One hospital alone might not have enough to offer meaning or recognize a problem, but when you aggregate it from around the Commonwealth, then you start seeing more and more trends. It’s the analytics part that then allows the authority to say we are noticing a problem that may not have been evident on the individual facility level,” Keenan said.

The Patient Safety Authority combs through about 230,000 to 240,000 incident reports from Pennsylvania hospitals, ambulatory surgical facilities, birthing centers and some abortion clinics each year to establish best practices that make medical facilities safer.

Separate from the Department of Health, the authority was created in 2002 by Act 13 and is funded by a fee collected from all hospitals and facilities that report to it.

Under the law, all medical facilities must report every medical mistake to the Pennsylvania Patient Safety Reporting System, operated by the authority. Hospitals reports near-miss ‘incidents’ and ‘serious events.’

“If someone is given the wrong medication, and it harms them, it would be a ‘serious event.’ If someone is prescribed the wrong medication, but the nurse notices at the bedside, and there was no harm to the patient, that would be reported to us as an ‘incident,’ ” Doering said.

The reports entered online by hospitals provide only the gender and age of the patient. But the more detailed the explanation of the incident, the more useful it is in identifying what caused it, Doering said.

“You might have a fall report that said patient fell on the floor, and we don’t know much more than that, but many reports go into a lot of detail about why that fall occurred. Was that patient trying to make their way to a toilet in the facility? Was there anyone there assisting patient? What the reason for it was,” Doering said.

When the PSA identifies common causes and repeated factors that lead to mistakes, it publishes guidelines, creates self-assessment forms and even sends representatives to hospitals to educate personnel.

The authority does not establish policies for hospitals.

A chief focus for the authority has been to reduce wrong-site surgeries.

“In theory, it’s 100 percent solvable,” said Dr. John Clarke, clinical director for the Pennsylvania Patient Safety authority and professor of surgery at Drexel University.

UPMC Chief Quality Officer Tami Minnie said that Clarke was “instrumental” in UPMC’s goal of removing wrong-site surgeries. In 2011, UPMC reported no wrong-site surgeries for the year.

The authority has eight liaisons who visit each hospital two to three times a year.

Akasha Chamberlain is a freelance writer for Trib Total Media.


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