Pennsylvania Patient Safety Authority Issues Annual Report for 2009

The Authority begins collecting the most comprehensive healthcare-associated infection (HAI) data from nursing homes in the nation and provides long-term care facilities with analytical tools to help reduce HAIs

HARRISBURG, Pa., April 28 /PRNewswire-USNewswire/ -- The Pennsylvania Patient Safety Authority issued its 2009 Annual Report containing healthcare-associated infection (HAI) data from nursing homes and hospitals. Pennsylvania is the only state in the nation to collect such comprehensive infection data from long-term care facilities.

"The Authority has worked very hard in the past year to ensure nursing homes are able to submit reports about healthcare-associated infections," Dr. Ana Pujols-McKee, chair of the Pennsylvania Patient Safety Authority, said. "While becoming the first state in the nation to collect such comprehensive infection information from nursing homes, Pennsylvania long-term care facilities have also embraced the opportunity to learn from events happening in their facilities."

Pujols-McKee said reporting began in June 2009 and in October 2009 the Authority provided nursing homes with analytical tools to study their infection data. Nursing homes are able to run real-time facility-specific reports for all categories of infections so they can identify trends and investigate risk factors for HAIs and their residents. The facilities can easily generate a selection of tables and charts to produce infection rates and raw data tables by date range, facility, care area and HAI subcategories.

The Authority analysts also do extensive research of the nursing home data and began publishing these analyses in the Pennsylvania Patient Safety Advisory. The three most common HAIs reported by nursing homes include: Respiratory Tract Infections (RTI)-subcategory Lower Respiratory Tract Infections (LRTI) reporting the highest rates within the RTI category; Skin and Soft Tissue Infection (SSTI)-subcategory Cellulitis reporting the highest rates within the SSTI category; and Gastrointestinal Infection (GI)-subcategory Clostridium difficile infection reporting the highest rates within the GI category.

"The transition to HAI reporting for nursing homes has been smooth from what our annual user survey suggests," Pujols-McKee said. "To ensure a smooth transition, the Authority conducted thirty live regional training sessions for over eleven hundred nursing home employees to introduce them to the Authority, the HAI reporting criteria and to show them how to enter reports into the reporting system."

Pujols-McKee added that nursing home facilities are eager to obtain any educational materials the Authority provides including Pennsylvania Patient Safety Advisory articles and educational webinars. Topics have included: methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infections (CDI).

The 2009 Annual Report also contains infection data from hospitals and ambulatory surgical facilities. The Authority has collected infection data from Pennsylvania hospitals since June 2004 through the Pennsylvania Patient Safety Reporting System (PA-PSRS). In 2007, a new law was passed making it mandatory for hospitals to report HAIs through the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN).  The Authority also developed a Healthcare-Associated Infection Advisory Panel to assist Pennsylvania agencies with implementation of the new law. Since February 2008 hospitals have submitted data through NHSN. The Authority has access to the reports in NHSN and analyzes them for its educational purposes.

In 2009, facilities submitted a full year of HAI data into NHSN. A report on catheter-associated urinary tract infections and central line-associated bloodstream infections is expected in May 2010 from the Pennsylvania Department of Health (DOH). A six-month snapshot of the data presented in a public report from DOH in January 2010 is cited in the Authority's 2009 Annual Report. The three most common HAIs reported in hospitals July-December 2008 include: urinary tract infections (24.82%), surgical site infections (22.23%) and gastrointestinal infections (18.15%).   

"The Authority will continue to look to the HAI Advisory Panel for guidance in taking the necessary steps forward to reduce healthcare-associated infections in Pennsylvania's hospitals and nursing homes," Pujols-McKee said. "I look forward to continuing the good work that has been done in the past year recognizing we've only just begun."

For more information about HAIs in hospitals and nursing homes go to page 35 of the 2009 Annual Report on the Authority's web site at www.patientsafetyauthority.org.

Patient Safety Liaison Program – Consultants to Help Improve Patient Safety

The Authority has continued aggressively pursuing its education mission by completing the hiring process of its Patient Safety Liaison (PSL) program and offering educational programs based in part upon conversations with Patient Safety Officers (PSOs) and PSL staff.

The Patient Safety Liaison program began in 2008 with a pilot program and one PSL in the Northeast region of Pennsylvania. Throughout 2009, the PSL program has grown. Today, six PSLs serve as consultants for each healthcare facility reporting under Act 13 of 2002 and Act 30 of 2006 (hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities). The PSL program is overseen by the Authority's director of Educational Programs. The most recent hires are in the Southeast region with the sixth PSL not expected to begin until mid-May 2010.

"The PSL program is now fully staffed so all hospitals and ASFs in Pennsylvania can have the same opportunities to engage in conversation with a representative from the Authority," Pujols-McKee said. "These conversations have generated new educational programs and collaboratives on a variety of topics like wrong-site surgery and the mislabeling of lab specimens."

Pujols-McKee said that along with the new educational materials, the Authority has been working on a new electronic forum called the Patient Safety Knowledge Exchange (PassKey). PassKey will give Pennsylvania PSOs an electronic forum to share policies, processes and information with one another about patient safety related issues. PassKey is expected to be implemented in June 2010.

"Just as the PSL program is geared toward engaging PSOs in conversation with the Authority, the PassKey program allows the conversation to continue between PSOs across Pennsylvania," Pujols-McKee added.

For more information on the Patient Safety Liaison program, its successes and new educational programs go to page 69 of the 2009 Annual Report. For more information on PassKey, go to page 74 of the 2009 Annual Report.

Educating Boards of Trustees and Top Level Management

In 2009, the Authority also completed its pilot program for educating Boards of Trustees and other senior leadership on patient safety through a program in conjunction with the Hospital and Healthsystem Association of Pennsylvania (HAP) using a curriculum developed by the American Hospital Association (AHA). The program was designed for senior leadership and board members to engage them in patient safety issues.

"The pilot sessions were very successful and useful in helping build a more regional program for all hospitals," Pujols-McKee said. "Plans are underway to educate 100 hospitals' boards of trustees and top level management over a three-year period. Our mission is to ensure all individuals from the top on down participate in making their facilities safer for patients."

For more information on the patient safety training for Boards of Trustees go to Page 77 of the 2009 Annual Report.

2009 Annual User Survey Results

Facilities also continue to make changes to improve patient safety according to the Authority's annual user survey. In December 2009, the Authority asked registered primary contacts at healthcare facilities in Pennsylvania to participate in an online survey. Those contacts include: Infection Prevention Designees (IPDs) and PSOs.

"Facilities continue to find Patient Safety Advisories useful [97%], relevant [96%], readable [99%], high in scientific quality [100%] and high in educational value [100%]," Pujols-McKee said. "We also know that over seventy percent of PSOs surveyed have made or plan to make changes in their facility based upon the guidance presented in the articles. With the help of the PSLs, I'm confident these numbers will continue to increase."

For more information on the annual user survey, go to page 79 of the 2009 Annual Report.

An Enhanced Web Site with More Consumer Information

In 2009, the Authority also unveiled a new web site with a tagline "Analyzing, Educating and Collaborating for Patient Safety." The tagline represents the Authority's mission to improve patient safety by analyzing data, educating healthcare facilities and the general public, and collaborating with healthcare facilities and organizations to further use the data. The new site features an enhanced search engine with easier navigation and features allowing users to share patient safety information more readily.

The Authority also enhanced the consumer page of its web site to provide patients and consumers with more information they can use to help prevent medical errors from occurring while using the healthcare system.

"Our data shows that patients have prevented medical errors from occurring because they weren't afraid to ask questions and participate fully in their healthcare," Pujols-McKee said. "Along with consumer tips that we develop based upon real cases in Pennsylvania, we also have brochures and links to other healthcare agencies that allow patients and their families to compare hospitals and healthcare providers."

For more information about the new web site, go to page 82 of the 2009 Annual Report.

An Executive Summary of the 2009 Annual Report is following this press release.  The complete Annual Report for 2009, as well as additional information about the Patient Safety Authority, is accessible on the Authority's web site www.patientsafetyauthority.org.

EXECUTIVE SUMMARY

The Pennsylvania Patient Safety Authority (Authority) is an independent state agency established under Act 13 of 2002, the Medical Care and Reduction of Error "MCare" Act. It is charged with taking steps to reduce and eliminate medical errors through data collection, identifying problems and recommending solutions that promote patient safety in hospitals, ambulatory surgical facilities, birthing centers and certain abortion providers. In June 2009, the Authority began collecting infection reports from nursing homes. The Authority's role is non-regulatory and non-punitive.

The Authority initiated statewide mandatory reporting in June 2004, making Pennsylvania the only state in the nation to require the reporting of Serious Events and Incidents (near misses). All reports are confidential and nondiscoverable, and they do not include any patient or provider names.  In 2007, the legislature added a chapter to the MCare Act that addressed the reporting of healthcare-associated infections (HAIs) in Pennsylvania and required infection reporting from nursing homes.  The law requires significant involvement by the Authority.

This annual report focuses on the primary activities, accomplishments and achievements of the Authority in 2009 including enhancement of the Authority's educational initiatives through the Patient Safety Liaison program, significant enhancements to the Authority's public web site, and efforts to increase our interaction with consumers/patients.  In addition, the report focuses on the activities conducted by the Authority regarding the drive to reduce and eliminate HAIs including the enhancement of the Pennsylvania Patient Safety Reporting System (PA-PSRS) to include Pennsylvania nursing homes' healthcare-associated infection reports, HAI analysis and training.

Aggregate data from 2009 facility reports will also be given for report volume, patient demographics and patterns in reports. This information will include analysis of the first six months of healthcare-associated infection data collected from Pennsylvania's over 700 nursing homes.  Samples of information provided in the Pennsylvania Patient Safety Advisories and the results of our annual survey of Patient Safety Officers are also highlighted.

For copies of the 2009 Annual Report, go to www.patientsafetyauthority.org.

The Authority's Education Mission Continues to Grow

The Authority continues to educate through its Pennsylvania Patient Safety Advisory and also through its outreach and collaboration efforts. The Patient Safety Liaison (PSL) program, begun in 2008, has flourished allowing the Authority and its facilities one-on-one conversations with Patient Safety Officers. These discussions have garnered several additional education initiatives. Along with the PSL program, the Authority completed its pilot program to educate Boards of Trustees and top level management through a program developed in partnership with the Hospital and Healthsystem Association of Pennsylvania (HAP) and the American Hospital Association (AHA). Plans to educate 100 hospitals' boards of trustees and top level management over a three-year period are in motion. The Authority has also expanded its continuing education program to include the Pennsylvania State Nurses Association (PSNA).

The Patient Safety Liaison Program

The Patient Safety Liaison (PSL) program began in 2008 with a pilot program and one Patient Safety Liaison in the Northeast region of Pennsylvania. Today, the program has five PSLs located throughout Pennsylvania.  In May 2010 when the sixth and final PSL begins work in the Southeast, each healthcare facility reporting under Act 13 of 2002 will have access to a PSL for consulting purposes. The program began, in part, because Patient Safety Officers requested "more of a presence" from the Authority. In April 2009, a Patient Safety Liaison was hired to consult in the Northwest region. In June 2009 a third PSL was hired to consult in the South Central region and in December 2009 a fourth PSL was hired to consult in the Southwest region. In February and March 2010 the fifth PSL was hired for the Southeast region of Pennsylvania. In 2009, the PSL Program experienced a growth not only in the number of employees in the program, but also in the amount of educational activities as a result of those new hires. As each PSL has gotten to know the Patient Safety Officers in their regions, the conversations have generated new educational programs and new collaborations on a variety of topics that include wrong-site surgery, methicillin resistant Staphyoloccus aureus (MRSA), mislabeling of lab specimens, the patient safety officer basic foundation course I, the beyond the basics course II, patient safety leadership and insights, root cause analysis, teamwork, human factors, highly reliable organizations (HRO), and failure mode and effects analysis training (FMEA).

Since the first PSL was hired in August 2007, the PSL program has gradually developed so that all healthcare facilities submitting reports through the Pennsylvania Patient Safety Reporting System (PA-PSRS) to the Patient Safety Authority have a consultant to help them improve patient safety in their facilities. The educational resources available to Patient Safety Officers (e.g. Pennsylvania Patient Safety Advisory articles, toolkits, consumer tips) are discussed at the first meeting with the PSL. In general, these meetings have been successful in fostering a relationship between the PSO and PSL. Sometimes in the first meetings the CEO or other management staff attend the meeting with the PSO to help the facility understand the concept behind the program and to engage all levels of staff in patient safety.

As the PSL program has developed throughout 2009 and into 2010, the PSLs and PSOs continue to help each other find new ways to engage in conversation not only with each other, but with other Pennsylvania healthcare facilities and state organizations. In 2010, the Patient Safety Knowledge Exchange program (PassKey) will provide an electronic forum for PSOs to communicate with one another about a host of patient safety related issues and to share policies, processes and information that have had a positive impact on patient safety in individual facilities. As the communication grows among healthcare facilities through the PSL program and PassKey, we anticipate that patient safety awareness will grow along with patient safety improvements.

Enhanced Public Website

The Authority unveiled its new web site and design in January 2009. The new site, www.patientsafetyauthority.org, features an enhanced search engine with easier navigation and features allowing users to share patient safety information more readily. The site also features a new tagline for the Authority: "Analyzing, Educating and Collaborating for Patient Safety." The tagline represents the Authority's mission to improve patient safety by analyzing data, educating healthcare facilities and the general public and collaborating with healthcare facilities and organizations to further use the data.

Specifically, the improved site makes it easier for users to find and distribute information in the following ways:

• Offers Pennsylvania-based healthcare information that is easier to read and find online with an enhanced search engine;
• Gives immediate access to the most recent information from the homepage featuring a spotlight section of "What's New";
• Allows users to browse-by-topic hundreds of Pennsylvania Patient Safety Advisory articles;
• Provides users with the means to distribute important Pennsylvania patient safety information through an "e-mail-to-a-friend" feature; and
• Offers a vast collection of educational tools and resources for healthcare providers and community groups to improve patient safety in Pennsylvania healthcare facilities.

Prior to the new web site launch, a small number of PSOs were given access to test its new features. They gave high marks to the site particularly for the new features that give Patient Safety Officers the ability to search Pennsylvania Patient Safety Advisory articles by discipline and topic and then e-mail any information to leaders and staff.

Towards the end of 2009, the Authority distributed its annual survey to Patient Safety Officers. Some questions revolved around the new web site and design. Of those PSOs who responded, 92% said the web site provides information in an easy-to-read format; 88% said the web site offers helpful ways to search for information and 83% said the web site provides relevant material.

Patient Safety Training for Trustees Continued in 2009

In 2009, the Authority completed its pilot program to educate executive management and Boards of Trustees about their role in improving patient safety. The initiative is designed to raise awareness and increase responsibility for patient safety by bringing it to the board level.

The Patient Safety Authority partnered with the Hospital and Healthsystem Association of Pennsylvania (HAP) and the American Hospital Association (AHA) to develop and execute the pilot program. An advisory panel composed of executive leaders and trustees from hospitals and health systems assisted the Patient Safety Authority and HAP in developing the customized educational program that would help foster the kind of senior level and board engagement needed for improved patient safety. A business model was developed and the Authority provided the funding needed to host training sessions in which 13 hospitals and approximately 300 persons participated.  The feedback from the sessions was positive overall with some suggestions for improvement given before rolling the program out statewide.

One attendee remarked:

"This conference provided the material and motivation necessary to complete a thorough review of our trustees' role in quality and safety. I fully endorse the program for all hospital and health system trustees charged with or interested in quality and safety of the services their organizations provide…Susquehanna Health anticipates using a modified version of this curriculum for future programmatic evaluation and strategic planning. We are grateful that this program helped stimulate our thinking and provided us with the motivation to make these changes."

Steven P. Johnson, FACHE, President and CEO, Susquehanna Health

In 2010, the Authority and HAP are moving beyond the pilot and plan to begin implementation of the program.  We are in the process of identifying and training education consultants who will conduct the training programs.  We are also working with groups of facilities and payers to develop additional funding sources.  Through this collaboration, the Authority and HAP hope to train 100 additional facilities over the next three years.

Speakers' Bureau and Information Booth

The Authority continues to reach out to the community through its speakers' bureau and information booth. Throughout 2009, hundreds of presentations were given to a host of healthcare facilities and organizations on a variety of patient safety issues. When possible, the Authority analyzes data from PA-PSRS that is directly related to the facility or organization topic being presented. These presentations offer their audience a first-hand look at what is going on in Pennsylvania's healthcare facilities and helps provide insight for setting patient safety goals.

The Patient Safety Authority information booth is available for healthcare fairs and other healthcare related events. Much of the information encourages the consumer to participate in their healthcare and gives information related to real events happening in Pennsylvania where the patient or family member helped prevent a medical error by asking questions. Please call the Authority at 717-346-0469 for more information about its speakers' bureau and information booth.

The Authority Increases Its Role in Fighting Healthcare-Associated Infections (HAI)

In 2007, the Pennsylvania legislature enacted Chapter 4 of the MCare Act.  This gave the Authority additional responsibilities in helping to reduce and eliminate infections in Pennsylvania.  In 2009, the Authority continued management of the Pennsylvania HAI Advisory Panel, continued to analyze HAI reports submitted by hospitals through the Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network (NHSN), and implemented the enhancements to PA-PSRS that enabled submission of HAI reports by nursing homes.  Also, the Authority's mission to educate healthcare facilities and nursing homes about healthcare-associated infections continued through healthcare-associated infection articles published in the Pennsylvania Patient Safety Advisories, the development and performance of educational webinars based on HAI issues in Pennsylvania and other live presentations and classes.  For example, the Authority made regional presentations to representatives of ambulatory surgical facilities on how to fight MRSA in their facilities.

According to MCare, the Department of Health is responsible for calculating and publicizing state-wide and specific hospital rates associated with HAI in Pennsylvania.  The Department of Health published the first report in January 2010.  This report covered data from July 2008 through December 2008.  A total of 13,771 HAIs were reported by Pennsylvania hospitals during the period July-December 2008. The most commonly reported HAIs were urinary tract infections (24.82%), surgical site infections (22.23%) and gastrointestinal infections (18.15%). Among the urinary tract infections, 69% were associated with a urinary catheter. Among the bloodstream infections, 68% were associated with a central line. More about hospital HAI reporting and the DOH report is detailed further in the "Healthcare-Associated Infections – Analyzing Reports" section of this annual report.

Nursing Homes Begin Reporting HAI through the Authority's Enhanced PA-PSRS System

In 2009, many Authority resources were directed towards providing an effective and efficient way for nursing homes to comply with the MCare Act in reporting HAI.  The Authority completed the significant enhancement of PA-PSRS to allow web-based entry of HAI events by nursing homes.  The Authority also provided live training at 30 sites where approximately 1,150 nursing home employees were educated on what was reportable and how these events should be reported.  The system went live in June 2009 when over 700 nursing homes began reporting.  In October and December 2009, the Authority also provided nursing homes with 13 analytical reporting tools within the PA-PSRS system that they can use to analyze their own data. 

From July through December 2009, 16,729 HAI events were submitted through PA-PSRS by Pennsylvania nursing homes.  With the implementation of PA-PSRS, Pennsylvania has begun collecting the most comprehensive healthcare-associated infection data from nursing homes in the nation.

More information about the hospitals and nursing homes healthcare-associated infection reports and analysis is available in the "Healthcare-Associated Infections – Analyzing Reports" section of this annual report.

Engaging Patients and Consumers

The Authority is committed to providing individual citizens, the consumers of healthcare, with information that can impact their experience in the healthcare arena by giving them tips on how they can receive quality care.

Consumer Tips and Brochures

In 2009, the Patient Safety Authority continued to develop and distribute consumer tips sheets with selected Advisory articles. These tips provide patients with more knowledge about specific healthcare topics. They include: medication errors, wrong-site surgery, color-coded wristbands, falls, MRSA, the risks for sleep apnea patients and the importance of knowing your medical history. There are many opportunities for patients and their loved ones to become involved in their healthcare, from making decisions about treatment protocols to assuring that providers are adhering to safe practices such as hand washing and verifying medications before administering them. The consumer tips sheets are another educational tool the Authority uses to reach out to the facilities and their patients. The Authority also developed a new brochure "How You Can Obtain Your Medical Records" for patients to know what they can expect when they need to obtain their medical information.

New Web Site Features Added for Patients and Consumers

Most recently, the Authority redesigned its consumer web page to make the consumer tips and brochures more easily accessible. Also included on the new consumer site is information on other state agencies responsible for hospital, healthcare provider and nursing home comparisons. These links are easily accessible from the Authority's new consumer web page, go to www.patientsafetyauthority.org, click on "Patients and Consumers."

Highlights of Data Submitted to the Pennsylvania Patient Safety Authority

Other highlights of data submitted to the Pennsylvania Patient Safety Authority and educational activities during calendar year 2009 follow.

• 528 hospitals, ambulatory surgical facilities, abortion facilities and birthing centers submitted 226,670 reports of Serious Events and Incidents to the Authority, an increase of 6,796 reports from 2008. In 2009, the Authority received 18,889 reports per month on average, an increase of 3% from 2008.
• Approximately 96% of all reports submitted by these facilities in 2009 were Incidents, or did not cause harm to the patient.  Approximately four percent of all reports were submitted as Serious Events, which indicates that the patient received some level of harm, ranging from minor, temporary harm to death.
• The number of Incident reports averaged 18,200 per month, an increase of 3.4% from 2008. Serious Event reports averaged 689 per month, a 4.3% decrease from the previous year. Part of the decrease can be traced to a certain event type (healthcare-associated infections or HAIs) some of which have previously been reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS). Since February 2008, hospitals report all HAIs through the Center for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN). However, taking into account the HAI reports from both years, Serious Events of other types increased 2.9% from 2008 to 2009.
• After approximately 1,150 nursing home representatives received training on reporting HAIs through PA-PSRS in 30 live sessions across Pennsylvania, 720 nursing homes began reporting HAIs to the Authority in June 2009. From July through December 2009, 16,729 HAI events were submitted to the Authority by nursing homes. The three most common infections reported are: Respiratory Tract Infections (RTI), Skin and Soft Tissue Infections (SSTI) and Gastrointestinal Infections (GI).
• In December 2009, the Authority surveyed Infection Prevention Designees (IPDs) at nursing homes. When asked how easy or difficult it was to submit a report through PA-PSRS, 94.7% said it was very easy or somewhat easy to submit reports,  5% were neutral and one respondent said it was somewhat difficult.
• Late in 2009, the Authority developed 13 analytical reporting tools for use within PA-PSRS by individual nursing homes.  Using these tools, nursing homes are able to view and print facility-specific reports for all categories of infections, so they can identify trends and work towards investigating risk factors for reducing and ultimately eliminating HAIs.
• Reports from hospitals accounted for 90.9% of all reports submitted. However, ambulatory surgical facility reports increased from 11.8 reports per facility in 2008 to 12.2. reports per facility in 2009.
• Statewide, the most frequently reported events in hospitals involved Errors related to Procedures/Treatments/Tests and Medication Errors (22%). Errors related to Procedures/Treatments/Test comprise 9% of reports involving harm and 6% of events contributing to or resulting in death. Medication errors comprise 4% of events involving harm and 1% of events contributing to or resulting in death.
• While Complications related to Procedures/Treatments/Tests comprise only 12% of reports overall in 2009, they comprise 42% of the reports of events involving harm and 59% of all reports of events resulting in or contributing to the patient's death.
• Reports in perinatal patients (those aged 20 days or younger) increased 6.7%, from 4,107 reports in 2008 to 4,381 reports in 2009. Also, reports involving children and adolescents (those aged 21 years or younger) increased 16.8% in 2009. 
• Reports in patients over age 65 also showed some changes in regard to Serious Events and Incidents. For example, elderly patients accounted for 64% of reports categorized as Falls in 2004 and 2005. This figure has declined steadily to 57.9% in 2009. Also, in 2009, reports with a primary categorization of Skin Integrity dropped from 73.1% occurring in patients over 65 in 2008 to 71.2% in 2009. Skin integrity reports include pressure sores, bruises and other skin-related conditions.
• In fulfilling its education mission in 2009, the Authority conducted a total of 16 on-site educational programs consisting of nine nursing home-related programs, four hospital/general healthcare programs and three ambulatory surgery facility-related programs.
• In 2009 the Authority continued to develop its Patient Safety Liaison program, led by the Director of Educational Programs. At the time this annual report went to press, the PSL hiring process has been completed with five PSLs working in the PSL role and one scheduled to begin in May 2010.  The PSLs will act as patient safety consultants to the hospitals, ASFs, birthing centers and certain abortion facilities that are required to report under the MCare Act.
• In 2009 more than 200 Patient Safety Officers attended educational programs developed by the Director of Educational Programs and PSLs. Many of these educational initiatives were spurred by feedback gathered from PSL visits with Patient Safety Officers.
• The PSLs are also engaged in several collaborative programs within their regions that include topics such as mislabeling of blood specimens, wrong-site surgery, falls and central line-associated bloodstream infections (CLABSI). 
• In a recent annual Authority survey, Patient Safety Officers (PSOs) that responded to the survey reported making 633 changes in their facilities in 2009 as a result of specific Patient Safety Advisory articles produced by the Authority.

For copies of the 2009 Annual Report, go to www.patientsafetyauthority.org.

SOURCE Pennsylvania Patient Safety Authority

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