Translating patient safety legislation into health care practice.
BACKGROUND
An independent state agency, the Authority is charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM (PA-PSRS): The Authority implemented PA-PSRS, a mandatory reporting and analysis system for both adverse events and near-misses, among 450 hospitals, birthing centers, and ambulatory surgical facilities. Pennsylvania is the only state to require the reporting of both adverse events and near-misses.
The Patient Safety Advisory is a quarterly publication containing articles about trends in reports submitted to PA-PSRS. The peer-reviewed articles include analysis of and lessons learned from PA-PSRS reports and evidence-based risk reduction strategies based on research in the clinical literature. To complement and reinforce the effectiveness of certain Advisory articles, the Authority has introduced electronic, educational tool kits on its Web site that can be downloaded. They include posters, draft policies, audio-slide presentations for staff training, and other materials related to clinical implementation of patient safety interventions and protocols.


CONCLUSIONS
In just over two years, the Authority has developed a program that turns reports into actionable items through the analysis and research of adverse events and near-misses.
Rabinowitz
Alan B K
AB
Pennsylvania Patient Safety Authority (PSA), Harrisburg, USA. arabinowit@state.pa.us
Clarke
John R
JR
Marella
William
W
Johnston
Janet
J
Baker
Laurie
L
Doering
Michael
M
D001363:Awards and Prizes; D006268:Health Facilities / Q000331:legislation & jurisprudence* / Q000592:standards; D006801:Humans; D033181:Information Dissemination / Q000331:legislation & jurisprudence*; D020407:Internet; D019221:Mandatory Reporting; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D010414:Pennsylvania; D011635:Public Health Administration / Q000331:legislation & jurisprudence*; D040442:Public Health Informatics; D017751:Safety Management / Q000331:legislation & jurisprudence* / Q000379:methods; D013219:State Government; D013597:Systems Analysis; D017749:Total Quality Management; D014342:Truth Disclosure