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: 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 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 Safety Events Impacting Hospitalized Patients Following Motor Vehicle Crashes: A Qualitative Study of Reports From Pennsylvania Hospitals

2021 ◽  
pp. 18-27
Author(s):  
Elizabeth Kukielka
Keyword(s):  
Patient Safety ◽  
Reporting System ◽  
Motor Vehicle ◽  
The United States ◽  
Motor Vehicle Crashes ◽  
Vehicle Crashes ◽  
Patient Harm ◽  
Contributing Factors ◽  
Safety Reporting ◽  
Communication Breakdowns

Motor vehicle crashes (MVCs) are a significant cause of morbidity and mortality in the United States and around the world. When a patient who has experienced trauma in an MVC presents to the emergency department, they may be unable to participate in their own care due to numerous factors, such as being unconscious, physically incapacitated, or suffering from confusion. To better characterize challenges with care of these patients, we analyzed reports of patient safety events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) related to MVCs, and we identified 282 reports for analysis that occurred from 2018–2020. Patients were more often male (58.9%; 166 of 282) than female (41.1%; 116 of 282), and they ranged in age from 1 to 93 years. A total of 13.1% (37 of 282) of reports were classified as serious events (i.e., events that resulted in patient harm), compared with 2.9% in the full acute care PA-PSRS database. Problems with monitoring or treatment were most common (43.3%; 122 of 282), followed by problems with evaluation (18.4%; 52 of 282), falls (11.7%; 33 of 282), problems with documentation (7.4%; 21 of 282), medication errors (7.4%; 21 of 282), and problems with transfers (6.4%; 18 of 282). Some potential contributing factors included communication breakdowns, lack of policies or protocols or unawareness about existing policies or protocols for treating certain patient populations, and prioritization of conditions related to an MVC over underlying health conditions.

scholarly journals Allergy-Related Medication Error Reports Submitted to a Large Patient Safety Reporting System

2019 ◽  
pp. 18-27
Author(s):  
Matthew Grissinger ◽  
Michael Gaunt ◽  
Alexander Shilman
Keyword(s):  
Patient Safety ◽  
Medication Error ◽  
Drug Allergy ◽  
Reporting System ◽  
Medication Use ◽  
Patient Harm ◽  
Event Reporting ◽  
Safety Reporting ◽  
Large Patient ◽  
Allergy Drug

Medication allergies can and do cause patient harm. Managing a patient’s allergies is a challenge for institutionsbecause failures can happen throughout the medication-use process. A total of 854 Medication Error events associated with patient allergies that occurred between July 2016 and June 2018 were reported through a large event reporting database. Analysts categorized these events into the following five stages: obtaining information from the patient, documenting allergies in the record, ordering medications, verifying orders, and administering medications. More than half (56.3%; n = 481) of the events reached the patient. Most likely to reach patients were events involving breakdowns when obtaining information from the patient (74.7%, n = 68 of 91) and administering medications (97.6%, n = 281 of 288). In reports that indicated allergies were properly documented, the majority (87.3%, n = 289 of 331) of the events that reached patients passed through two or more stages. Organizations may use this information to inform proactive efforts to implement system-based strategies to improve the medication-use process. Keywords: drug allergy, drug reaction, medication errors, medication safety, patient safety

Remaking Retirement

2020 ◽  
Keyword(s):  
Interest Rates ◽  
Older Workers ◽  
Older Persons ◽  
The United States ◽  
Older Population ◽  
The Past ◽  
Cost Of Education ◽  
The World ◽  
Low Interest Rates ◽  
Key Aspects

Around the world, people nearing and entering retirement are holding ever-greater levels of debt than in the past. This is not a benign situation, as many pre-retirees and retirees are stressed about their indebtedness. Moreover, this growth in debt among the older population may render retirees vulnerable to financial shocks, medical care bills, and changes in interest rates. Contributors to this volume explore key aspects of the rise in debt across older cohorts, drill down into the types of debt and reasons for debt incurred by the older population, and review policies to remedy some of the financial problems facing older persons, in the United States and elsewhere. The authors explore which groups are most affected by debt, and they also identify the factors causing this important increase in leverage at older ages. It is clear that the economic and market environments are influential when it comes to saving and debt. Access to easy borrowing, low interest rates, and the rising cost of education have had important impacts on how much people borrow, and how much debt they carry at older ages. In this environment, the capacity to manage debt is ever more important as older workers lack the opportunity to recover for mistakes.

Pharmacy Leadership Amid the Pandemic: Maintaining Patient Safety During Uncertain Times

2021 ◽  
pp. 001857872110375
Author(s):  
Irene Derrong Lin ◽  
John B. Hertig
Keyword(s):  
Patient Safety ◽  
Safety Data ◽  
Clinical Effectiveness ◽  
World Health ◽  
Leadership Strategies ◽  
Pharmaceutical Supply Chain ◽  
The World ◽  
Health Organization ◽  
Pharmacy Leaders ◽  
Effective Treatments

The relentless surges of global severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections that caused the Covid-19 disease had pressured researchers and regulators to develop effective treatments quickly. While studying these therapies amid the pandemic, threats to patient care were reported, including (1) maintaining adequate safeguards as clinical effectiveness and safety data evolves, (2) risks from online counterfeit medications, and (3) disruption of the global pharmaceutical supply chain. This article discusses these patient safety threats and suggests strategies that promote patient safety, foster medication intelligence, and mitigate drug shortages. As the world continues to develop safe and effective treatments for Covid-19, patient safety is paramount. In response to the World Health Organization (WHO) Global Safety Challenge: Medication Without Harm, leaders must establish effective approaches to improve medication safety during the pandemic. Successfully integrating these leadership strategies with current practices allows pharmacy leaders to implement robust systems to reduce errors, prevent harm, and advocate for patient safety.

Improved quality of reporting safety data of medication in paediatric randomised controlled trials

2021 ◽  
pp. archdischild-2020-321197
Author(s):  
Taco Jan Prins ◽  
Corine Rollema ◽  
Eric van Roon ◽  
Tjalling de Vries
Keyword(s):  
Adverse Events ◽  
Randomised Controlled Trials ◽  
Safety Data ◽  
Drug Event ◽  
Controlled Trials ◽  
Quality Of Reporting ◽  
Event Reporting ◽  
The Past ◽  
Randomised Controlled

ObjectiveEvaluating the reporting of safety data of medication in paediatric randomised controlled trials (RCTs) in 2017–2018 compared with our earlier study.DesignLiterature search with a systemic appraisal of adverse drug event reporting.Main outcome measuresQuality of reporting of safety data using Consolidated Standards of Reporting Trials (CONSORT) and Ioannidis scores in paediatric drug RCTs. The CONSORT score consists of nine recommendations of the CONSORT Group issued to improve the quality of reporting adverse events. The Ioannidis score is based on these advices. We considered a CONSORT score of at least 6 and an Ioannidis score of at least 3 as sufficient.ResultsWe reviewed 100 RCTs published in 2017 and 2018. Ninety-four (94%) articles mentioned adverse events compared with 78% in the earlier study. Fifty-seven per cent used a standardised method for reporting adverse events compared with 34% in our earlier study. In 26 of the articles, the expected adverse events were defined, and 27 articles had a preset standardised scale for adverse events. Of these, 62 articles (62%) had a CONSORT score of 6 or higher compared with 18% in 2010. In the present study, 67% had an Ioannidis score of 3 or higher, whereas in the earlier study this was 29%. Both differences are statistically significant (p<0.05).ConclusionsReporting safety data in paediatric RCTs has improved over the past 10 years. However, there is still room for improvement and for further improvement. Authors and editors should give more attention to methods for collecting, reporting and presenting safety data of RCTs in studies and manuscripts.

scholarly journals Developing Asia – Dynamic but fractured

2021 ◽  
pp. 211-229
Author(s):  
Robert Wihtol
Keyword(s):  
Economic Transition ◽  
Regional Cooperation ◽  
The United States ◽  
Authoritarian Regimes ◽  
Territorial Disputes ◽  
Socialist Market Economy ◽  
The Past ◽  
Governance Systems ◽  
The World ◽  
Socialist Market

In the past seventy–five years, developing Asia has transformed more rapidly than any other region. What is behind this success? Will Asia go on to lead the world, or will its rise encounter obstacles? Asia is politically diverse, with democracies, hybrid governments and numerous authoritarian regimes. Several are unstable. Paths to prosperity have varied, including the East Asian model, China’s “socialist market economy”, Indian self–reliance, and economic transition in Central Asia. Regional cooperation is chronically weak, due to the youthfulness, dispersion and diversity of Asia’s sovereign states. China’s rise threatens to fracture the region further. As the region emerges from the Covid–19 crisis, East Asia is well positioned to lead an economic recovery. However, many challenges remain. Political and governance systems are weak. Territorial disputes could escalate into open conflict, including Taiwan. Human capital is poorly developed, and populations are aging. Finally, the region could be polarized between the United States and China.

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