scholarly journals 2020 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents From the Nation's Largest Event Reporting Database

2021 ◽  
Author(s):  
Shawn Kepner ◽  
Rebecca Jones
Keyword(s):  
Patient Safety ◽  
Acute Care ◽  
Safety Data ◽  
The United States ◽  
Healthcare Facilities ◽  
Safety Reporting ◽  
Safety Event ◽  
Acute Care Facilities ◽  
Acute Healthcare ◽  
Reporting Rates

Pennsylvania is the only state that requires acute healthcare facilities to report all events of harm or potential for harm. With over 3.9 million acute care event reports, the Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world. Of the 278,548 patient safety event reports submitted by Pennsylvania’s acute care facilities in 2020, 97.2% were from hospitals and 2.7% were from ambulatory surgical facilities (ASFs). The remaining 0.1% were from birthing centers and abortion facilities. The vast majority of the 2020 reports were Incidents (97.0%) rather than Serious Events (3.0%). For each of the last five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, accounting for 32.1% of all submitted acute care event reports in 2020. The second, third, and fourth most frequently reported event types were Medication Error, Complication of Procedure/Treatment/Test, and Fall, accounting for 16.7%, 16.2%, and 11.8% of submitted reports in 2020, respectively. The reporting rates for hospitals in Q1 and Q2 2020 were 32.8 and 31.5 reports per 1,000 patient days, respectively. For ASFs, the reporting rates for Q1 and Q2 2020 were 9.8 and 8.4 reports per 1,000 surgical encounters, respectively.

scholarly journals 2019 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents From the Nation's Largest Event Reporting Database

2020 ◽  
Author(s):  
Shawn Kepner ◽  
Rebecca Jones ◽  
Caitlyn Allen ◽  
Daniel Glunk ◽  
Eric Weitz ◽  
...  
Keyword(s):  
Patient Safety ◽  
Acute Care ◽  
Reporting System ◽  
Safety Data ◽  
The United States ◽  
Event Reporting ◽  
Healthcare Facilities ◽  
Safety Reporting ◽  
The Past ◽  
The World

Pennsylvania is the only state that requires healthcare facilities to report all events of harm or potential for harm. Serious Events and Incidents are reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS)*, which is the largest repository of patient safety data in the United States, and one of the largest in the world, with over 3.6 million acute care records. The overwhelming majority (97.1%) of all acute care event reports are Incidents. For 2019, there were 284,847 Incidents and 8,553 Serious Events for a total of 293,400 reported events. The counts of all events and the percentage that are Serious Events reported over the last eight years are provided in Figure 1. The total number of event reports has increased during the last four years. The number of reported Serious Events has increased over the past three years with the largest annual increase occurring in 2019 (+5.7%). This article will show details of the PA-PSRS acute care data along with longitudinal and categorical insights that can be used for improving patient safety.

scholarly journals 2020 Pennsylvania Patient Safety Reporting: Updated Acute Care Reporting Rates

2021 ◽  
pp. 54-56
Author(s):  
Shawn Kepner
Keyword(s):  
Patient Safety ◽  
Acute Care ◽  
Recent Article ◽  
Hospital Patient ◽  
Safety Reporting ◽  
Care Facilities ◽  
Fall Rates ◽  
Acute Care Facilities ◽  
Reporting Rates ◽  
Complete Reporting

In our recent article summarizing 2020 data from acute care facilities in Pennsylvania, reporting rates and fall rates were provided for Q1 and Q2 2020 based on the latest data we had available at the time of publication. Given that 2020 was an unpredictable year in healthcare, any forecasting of rates for Q3 and Q4 2020 would have been unreliable. Therefore, this data snapshot serves to complete reporting rates for 2020 now that all hospital patient days and surgical encounters data from 2020 have been made available for rate calculations.

scholarly journals 604. Gram-Negative Bacilli Carrying Multiple Carbapenemases: the United States, 2012–2018

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S283-S283
Author(s):  
David Ham ◽  
Garrett Mahon ◽  
Sandeep Bhaurla ◽  
Sam Horwich-Scholefield ◽  
Liore Klein ◽  
...  
Keyword(s):  
Public Health ◽  
United States ◽  
Acute Care ◽  
Treatment Options ◽  
The United States ◽  
Culture Collection ◽  
Health Departments ◽  
Gram Negative ◽  
Healthcare Facilities ◽  
Acute Care Facilities

Abstract Background Gram-negative bacilli carrying multiple carbapenemase genes (multi-CP-GNB) present an emerging public health threat; to date, most isolates reported in the literature have been from outside the United States. We reviewed multi-CP-GNB reported to CDC. Methods Reports of multi-CP-GNB isolates carrying genes encoding >1 targeted carbapenemases (i.e., KPC, NDM, OXA-48-type, VIM, or IMP) were received from healthcare facilities, health departments, and public health laboratories, and included isolates tested through the AR Laboratory Network (ARLN) beginning in 2017 as well as isolates sent to CDC for reference testing. Epidemiologic data were gathered by health departments during public health investigations. Results From October 2012 to November 2018, 111 multi-CP-GNB isolates from 71 patients in 20 states were identified. Two patients had three different multi-CP-GNB and one patient had two different multi-CP-GNB. The majority of cases (76%) were reported in 2017 or later, after ARLN testing began. Among patients with multi-CP-GNB, the most common organism-mechanisms combination was Klebsiella pneumoniae carrying NDM and OXA-48-type enzymes (table). Urine (44%) and rectal (20%) were the most frequent specimen sources for isolates. The median age of patients was 63 years (range 2–89 years); most had specimens collected at acute care hospitals (87%) or post-acute care facilities (9%). Of 50 patients with information available, 37 traveled internationally in the 12 months prior to culture collection. Among these, 88% were hospitalized for ≥1 night while outside the United States with 10 countries reported, of which India was most common (n = 18). All 5 patients with Pseudomonas aeruginosa co-carrying carbapenemases reported recent hospitalization outside the United States. Conclusion The multi-CP-GNB reported to CDC include diverse organisms and carbapenemase combinations and often harbored carbapenemases from different β-lactamase classes, which may severely limit treatment options. Healthcare exposures outside the United States were common; providers should ask about this exposure at healthcare admission and, when present, institute interventions to stop transmission in order to slow further US emergence. Disclosures All authors: No reported disclosures.

A descriptive study of bathing practices in acute care facilities in the United States

2019 ◽  
Vol 47 (1) ◽  
pp. 23-26 ◽  
Author(s):  
Lizbeth P. Sturgeon ◽  
Dawn Garrett-Wright ◽  
Grace Lartey ◽  
M. Susan Jones ◽  
Lorraine Bormann ◽  
...  
Keyword(s):  
United States ◽  
Acute Care ◽  
Descriptive Study ◽  
The United States ◽  
Care Facilities ◽  
Acute Care Facilities

scholarly journals How Safety Is Compromised When Hospital Equipment Is a Poor Fit for Patients Who Are Obese

2020 ◽  
pp. 48-56
Author(s):  
Eliabeth Kukielka
Keyword(s):  
United States ◽  
Reporting System ◽  
Healthcare Providers ◽  
The United States ◽  
Healthcare Facilities ◽  
Safety Reporting ◽  
Imaging Department ◽  
Skin Tears ◽  
Hospital Equipment ◽  
Surgical Unit

Obesity is common, serious, and costly, and according to recent data, its prevalence is on the rise in the United States. Event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) indicate that some healthcare facilities do not have the necessary equipment to monitor and care for some individuals in this patient population, leading to embarrassment for patients, delays in care, and injuries to patients. An analysis of 107 events related to monitoring and patient care for patients who are obese submitted to PA-PSRS from 2009 through 2018 showed that imaging equipment, especially MRI and CT scanners, was most often implicated in event reports (49.5%; 53 events); other equipment included stretchers (24.3%; 26 events) and wheelchairs (11.2%; 12 events). Events most often occurred in an imaging department (30.8%; 33 events) or a medical/surgical unit (21.5%; 23 events). Analysts determined that 80 events (74.8%) resulted in a delay in care and that 44 events (41.1%) resulted in temporary harm to the patient, including skin tears and abrasions. Healthcare providers may not be able to prevent delays in care resulting from the unavailability of adequate equipment for patients who are obese, but they may be able to prevent harm and embarrassment for patients through proactive assessment.

scholarly journals The SHIELD Orange County Project: Multidrug-resistant Organism Prevalence in 21 Nursing Homes and Long-term Acute Care Facilities in Southern California

2019 ◽  
Vol 69 (9) ◽  
pp. 1566-1573 ◽  
Author(s):  
James A McKinnell ◽  
Raveena D Singh ◽  
Loren G Miller ◽  
Ken Kleinman ◽  
Gabrielle Gussin ◽  
...  
Keyword(s):  
Nursing Homes ◽  
Acute Care ◽  
Orange County ◽  
Multidrug Resistant ◽  
Resistant Organism ◽  
Healthcare Intervention ◽  
Healthcare Facilities ◽  
Care Facilities ◽  
Acute Care Facilities

Abstract Background Multidrug-resistant organisms (MDROs) spread between hospitals, nursing homes (NHs), and long-term acute care facilities (LTACs) via patient transfers. The Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County is a regional public health collaborative involving decolonization at 38 healthcare facilities selected based on their high degree of patient sharing. We report baseline MDRO prevalence in 21 NHs/LTACs. Methods A random sample of 50 adults for 21 NHs/LTACs (18 NHs, 3 LTACs) were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum β-lactamase–producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, skin (axilla/groin), and peri-rectal swabs. Facility and resident characteristics associated with MDRO carriage were assessed using multivariable models clustering by person and facility. Results Prevalence of MDROs was 65% in NHs and 80% in LTACs. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). CRE prevalence was higher in facilities that manage ventilated LTAC patients and NH residents (8% vs <1%, P < .001). MDRO status was known for 18% of NH residents and 49% of LTAC patients. MDRO-colonized adults commonly harbored additional MDROs (54% MDRO+ NH residents and 62% MDRO+ LTACs patients). History of MRSA (odds ratio [OR] = 1.7; confidence interval [CI]: 1.2, 2.4; P = .004), VRE (OR = 2.1; CI: 1.2, 3.8; P = .01), ESBL (OR = 1.6; CI: 1.1, 2.3; P = .03), and diabetes (OR = 1.3; CI: 1.0, 1.7; P = .03) were associated with any MDRO carriage. Conclusions The majority of NH residents and LTAC patients harbor MDROs. MDRO status is frequently unknown to the facility. The high MDRO prevalence highlights the need for prevention efforts in NHs/LTACs as part of regional efforts to control MDRO spread.

The United States Army Medical Command, becoming a learning organization

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Bonnie Hartstein ◽  
Edward Yackel
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
High Reliability ◽  
Safety Data ◽  
The United States ◽  
Care Quality ◽  
The Body ◽  
Content Type ◽  
Army Medical ◽  
System Changes

Purpose This study aims to describe how the Army and the Army Medical Department matured as a learning organizations (LOS) during the period after the 2014 Military Health System Review through the incorporation of changes aimed at improving patient safety, data transparency and becoming a high reliability organization. This study explores the relationship between HRO and LO concepts by adding to the body of knowledge in both disciplines. Design/methodology/approach Four large scale system changes are presented and evaluated against the principles of the LO. Metric data were collected longitudinally and presented as submitted to several nationally recognized organizations in health-care quality and safety. Post initiative observations are paired with a corresponding LO principle to assess MEDCOM’s maturation as a LO. System changes/improvements and the advancement of LO principles are discussed. Findings System improvements, analyzed critically alongside paired LO principles, show strong correlation between high reliability and LO principles. Despite inherent institutional barriers, this study demonstrates that when leveraged effectively, the leadership hierarchy and command culture can accelerate transformation into an LO. Originality/value This study explores changes implemented in the U.S. Army Medical Command (MEDCOM), as it evolved as a stronger LO. It demonstrates how health-care organizations and other high-risk industries that embrace high reliability concepts will become better LO, and expands current knowledge on how LO concepts in health care can affect better system accountability and improved patient safety. Organizations can learn from MEDCOM’s journey changes that can hasten progress toward adoption of LO principles, especially in hierarchical organizations.

Qualitative Review of Wrong-Site Surgeries: What Side Will My Surgery Take Place?

2018 ◽  
Vol 7 (1) ◽  
pp. 267-273
Author(s):  
Anoosha Moturu ◽  
Jessica Howe ◽  
Grace Tran
Keyword(s):  
Patient Safety ◽  
The United States ◽  
Medical Documentation ◽  
Contributing Factors ◽  
Related Factors ◽  
Qualitative Review ◽  
Safety Event ◽  
Word Search ◽  
Communication Breakdowns ◽  
Wrong Site

Wrong site surgeries (WSS) are classified as “never events” and signify adverse events that are preventable. The prevalence of procedures in the wrong location is up to 50 WSS per week in the United States. Informed consent (IC) related contributing factors include communication breakdowns between staff and across units, lack of cross-checking documents, equipment-related issues, and lack of automation in document coordination. As part of a patient safety initiative, a qualitative review of IC and WSS-related factors was conducted using patient safety event (PSE) data within a large healthcare system in the mid-Atlantic region. A word search query of the PSE database containing 132,683 PSEs from 2009 to 2017 was performed using a comprehensive codebook, and inter-rater reliability was established. Qualitative analysis of the PSE data indicated highest frequencies of the following codes: mAbsence of consent for treatment (25.7%), Incorrect or missing information recorded in the IC form (15.5%), and Ambiguity in laterality of the procedure on IC form/other medical documentation (12.5%). These contributing factors often lead to Late procedure start times (6.6%) and New consent document procurement (6.42%). These findings inform the need for system-based interventions to reduce risk. A targeted intervention focused on improving the design of IC forms and other medical documents could address some of these vulnerabilities. Developing a system-based approach to cross check procedure information could increase the reliability of system safeguards to reduce the risk of potential patient harm.

scholarly journals Where There’s Smoke: Validating a Nonproprietary Single-Item Burnout-Impacting-Safety Scale

2021 ◽  
pp. 34-44
Author(s):  
Amanda Pearl ◽  
Steve Mrozowski ◽  
Daniel Shapiro
Keyword(s):  
Patient Safety ◽  
High Risk ◽  
Healthcare Providers ◽  
The United States ◽  
Cutoff Score ◽  
Single Item ◽  
Survey Item ◽  
Safety Event ◽  
Clinical Departments ◽  
The Impact

This study aimed to assess the utility of a single survey item to predict the impact of burnout on safety and quality of healthcare providers as perceived by their colleagues. The primary objective is to determine if the item predicts the frequency of patient safety event reports within certain clinical departments. The secondary objective will be to determine if there is an acceptable cutoff score for the item which predicts low versus high numbers of safety events reported by healthcare providers in each clinical department. Participants were 424 healthcare providers in an academic medical center in the mid-Atlantic region of the United States. The item was designed to assess for the perception of the impact of burnout on work in terms of quality or safety using a 5-point Likert scale. Data from a patient safety event reporting system was accessed for the year of survey completion (2017). A negative binomial regression was used to assess the ability of the item to predict reported patient safety event reports. The item was found to significantly predict objective safety event data. Sensitivity and specificity, as well as receiver operating characteristic (ROC) curve analyses, were conducted to determine appropriateness of cutoff scores to identify low- and high-risk clinical departments. The item was found to demonstrate adequate sensitivity (82%) using a cutoff score of 4 on the survey item. However, the area under the curves (AUCs) which assess diagnostic accuracy fell in the poor range. These results suggest that healthcare administrators could deploy this single item as a brief pulse or screener of teams of individuals who are within a work unit and use a cutoff score of 4 as a means to assess for hot spots where healthcare provider burnout may be putting patients at high risk in terms of safety.

Sign in / Sign up

Export Citation Format

Share Document