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Patient Safety Authority Issues Annual Report for 2007
Date:4/30/2008

edication 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
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SOURCE Pennsylvania Patient Safety Authority
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