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

for the effort to combat infections in Pennsylvania's hospitals and nursing homes. While developed and managed by the Authority, the Advisory panel is available to counsel all state agencies with responsibilities related to Act 52. More information about Act 52 and the Advisory Panel can be found on page 15.

Data Collection - Patterns and Trends in Reports Collecting and analyzing reports of Serious Events and Incidents are vital components to the Authority's educational initiatives. The reports are submitted through the Pennsylvania Patient Safety Reporting System, known as PA-PSRS.

The data was submitted by Pennsylvania's 511 hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities. These facilities submitted 211,983 reports; 7,277 were classified as Serious Events (adverse events with patient harm) and 204,706 classified as Incidents (near misses and events that reached the patient but did not cause harm) into PA-PSRS in 2007. Almost 97% of the events in 2007 were classified as Incidents. The Authority believes that robust submission of Incident reports generally indicates a positive culture of safety within a facility that reflects open communication and attention to patient safety efforts. In Figure 1, report volume in 2007 showed an increase of 16,151 reports over 2006, with an increase in both Incidents (8%) and Serious Events (5%).

[See Figure 6 on page 28 of the Annual Report]

When reporting an event to the Authority, a facility uses a classification system or "taxonomy" to characterize the occurrence they are reporting. A facility classifies a report by identifying what PA-PSRS defines as the "Event Type." The Event Type essentially answers the most basic question about an occurrence: "What happened?" While there is considerable detail within the taxonomy, at its most basic level, the PA-PSRS classification contains nine Event Types.

[See Figure 14 on page 36 of the Annual Rep
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SOURCE Pennsylvania Patient Safety Authority
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