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

eport shows that there is substantial variation in the number of reports submitted by different healthcare facilities. While a vast majority of hospitals are reporting Serious Events (events that cause harm to the patient) and Incidents (events that do not cause harm to the patient); the volume varies greatly from facility to facility.

Doering said the Authority believes the main reason facilities are reporting inconsistently is because there are differences among them regarding how to interpret language in Act 13 as to what is reportable. He added that the Authority will work with the Department of Health, which is the state regulator of reporting, to offer facilities more guidance as to what should be reported to bridge the gap in facility reporting levels. The inconsistency is of concern to the Authority.

"These differences in reporting by different types of facilities is concerning for several reasons," Doering said. "If events aren't reported, we may be missing opportunities to share information that could help to prevent similar events from happening in other facilities."

"Another concern is that when facilities have different interpretations of the Serious Event definition, a patient who would receive written notification if they were harmed in one facility might not be notified if they were in another facility," Doering added. "It is important for open communication to occur between the patient and provider when a Serious Event occurs so that everyone understands what happened."

He explains that according to Act 13 when a Serious Event occurs in a facility the patient that suffered from the Serious Event must receive written notification from the facility explaining what happened. The provision was added in Act 13 to encourage providers to communicate more openly with their patients.

Doering said many facilities have been asking for further guidance about reporting. The Authority has provided facilities with progr
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SOURCE Pennsylvania Patient Safety Authority
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