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

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 http://www.psa.state.pa.us 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
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SOURCE Pennsylvania Patient Safety Authority
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