Patient Safety Authority

23/07/2025

Andrea Colfer has been a driving force for innovation at Children’s Hospital of Philadelphia, from proposing an enterprisewide refresh of major event analysis to creating a book club to spark conversation around patient safety. In her role and beyond, she always advocates for including the voice of the patient or family as the team considers any harm and gives every event review careful thought and attention.

Read more and share her story: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/iaps-2025-individual-impact.aspx

21/07/2025

The Penn Medicine Enterprise High Sensitivity Troponin Implementation Team developed chest pain algorithms to reduce the risks associated with the use of high-sensitivity cardiac troponin assays (hs-cTn), such as diagnostic errors, inappropriate admissions, and rise in cardiology consultations and unnecessary imaging. Implemented across five participating hospitals, the initiative generated over $3.9 million in savings within 10 months by reducing length of stay, enhancing patient throughput, and increasing ED capacity.

Read more and share their story: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/iaps-2025-improving-diagnosis.aspx

18/07/2025

Sarah Prylinski at UPMC Hamot led the development and implementation of a groundbreaking street medicine program that helps meet the needs of individuals experiencing homelessness. Whether in shelters or on the streets, she provides education on medication, administers vaccines, cares for wounds and infections, schedules and attends medical appointments with patients, and more—improving their access to healthcare and fostering trust and dignity in this vulnerable population.

Read more and share her story: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/iaps-2025-healthcare-disparity.aspx

17/07/2025

The summer 2025 edition of THE LOWDOWN, our quarterly infection prevention newsletter for long-term care facilities, focuses on outbreaks and some of their associated diseases.

Long-term care facilities present unique challenges during an infectious disease outbreak. Resident risk factors, such as comorbidities, shared common spaces and equipment, and facility factors (e.g., staffing shortages or poor infection prevention practices) provide the opportunity for diseases to spread rapidly and cause an outbreak. This issue provides resources to assist you in preparing for an outbreak situation.

Read, print, and share it with your staff and colleagues: https://patientsafety.pa.gov/pst/Pages/Infection%20Prevention/the-lowdown-summer2025.aspx

16/07/2025

When Penn Medicine Rehabilitation noted an increase in patient elopements (patients leaving the hospital outside of approved activities), this team developed an action plan to reduce the number of events. Noting that many elopements occurred between 6 and 9 p.m., often to purchase food or snacks, they implemented several interventions, including providing vending machines for patients—successfully reducing the number of elopements.

Read more and share their story: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/iaps-2025-commitment-to-safety.aspx

14/07/2025

The staff at UPMC St. Margaret Harmar Outpatient Center have demonstrated a commitment to continuous improvement, collaboration, and innovation in patient safety—for example, implementing a dedicated cellphone for communicating with patients, as well as new procedures for pre- and postoperative calls. With an additional focus on pain reassessment management and pediatric orthopedic care, their efforts have enhanced patient outcomes and satisfaction.

Read more and share their story: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/iaps-2025-ambulatory-care.aspx

11/07/2025

JUST PUBLISHED: When a patient is transferred from one hospital or facility to another, one important step in the hand-off process is admission medication reconciliation (AdmMedRec), during which the patient’s current medications are recorded and a healthcare provider reviews the list to determine whether to continue, hold, substitute, or discontinue each medication. Medication errors may occur during AdmMedRec, resulting in patients not receiving one or more doses of an important medication. There are many challenges to AdmMedRec, including low compliance rates and a lack of a defined process or formal training.

When a large academic medical center noted multiple errors related to AdmMedRec, an interdisciplinary team investigated the causes and designed and implemented interventions, which were refined in rapid, iterative “Plan-Do-Study-Act” cycles. Through this improvement initiative, they introduced a standardized AdmMedRec workflow, developed education (including one-on-one training and a tip sheet), introduced an AdmMedRec dashboard in their electronic health record, monitored medication reconciliation status and proactively reached out to providers, and collected feedback. These comprehensive and collaborative efforts resulted in significant increases in AdmMedRec completion rates in the facilities in which these interventions were rolled out—as well as an anticipated decrease in the number of medication errors.

Read and share this new article:

By Kai Xu, Nina Renzi & 1 more. Medication errors are common, especially during care transitions, and associated with adverse patient outcomes. Effective medication reconciliation is essential to prevent errors. Multiple medication discrepancies were documented on admission to...

02/07/2025

Are you a new infection preventionist (IP)? Or maybe you just want to brush up on Pennsylvania healthcare-associated infection (HAI) reporting requirements?

After completing the first in this two-part series, you’ll understand your role as an IP, how key components of MCARE relate to infection control, the elements of an infection control plan and infection control committee, and the importance of HAI and utilization data reporting. PSA tools and resources will also be provided for ongoing usage.

Watch and share:

Are you a new infection preventionist (IP)? Or maybe you just want to brush up on Pennsylvania healthcare-associated infection (HAI) reporting requirements?A...

24/06/2025

Last week, PSA infection prevention advisors JoAnn Adkins and Amanda Bennett presented at the APIC - Infection Prevention and You Annual Conference & Expo in Phoenix. Their session covered how to interpret polymerase chain reaction (PCR) testing for infectious diseases and how it informs antibiotic therapy in comparison to conventional culture and sensitivity (C&S) testing. From all accounts, this informative discussion was a big success and was well received by participants. Congratulations, JoAnn and Amanda!

06/06/2025

Our newsletters keep you up to date about what’s happening at the Patient Safety Authority, in Pennsylvania facilities, and in healthcare today. This month, learn about how to prevent wrong dose errors with U-500 insulin. Also: watch our video series on telemetry monitoring in Pennsylvania and read about how event reporting improves safety.

Please read and share this information to ensure everyone has the knowledge and tools to help keep safe: https://conta.cc/3Sv0HSN

05/06/2025

JUST PUBLISHED: Patient frailty is a significant predictor of postoperative morbidity and mortality. The collective body of research over recent years has made a strong argument for preoperative use of a Risk Analysis Index (RAI) tool to evaluate the patients for frailty, as a proxy for physiologic reserve. The RAI tool can be completed by the patient/representative or staff and the scores are then tallied to estimate the degree of patient frailty.

Higher RAI scores indicate that a patient would have greater frailty-associated risks. For ease of interpretation, the RAI scores are often grouped into the following four categories of patient status: robust, normal, frail, or very frail.

This tool is intended to be used with patients who are potential candidates for nonemergent or elective surgeries. Use of the RAI to identify patients who are frail or very frail may guide the surgeon and patient to consider preoperative rehabilitation (i.e., prehabilitation) or to not have surgery (i.e., opting for nonoperative treatments for symptom management, sometimes including palliative care).

Read more and share:

By Matthew A. Taylor, Daniel E. Hall. More than 31,000 events involving complications related to a surgery or invasive procedure were reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in the five-year period between...

04/06/2025

Check out this informative webinar on "Preventing Falls in Ambulatory Care: Strategies for Safer Patient Environments," which discusses the challenges of preventing patient falls in ambulatory healthcare settings. In this session, we welcomed the Quality and Safety Team of the Clinical Practices of the University of Pennsylvania (CPUP), Patricia Macolino, director of Quality Ambulatory Care, and Katie Fox, master improvement advisor, to share their quality improvement efforts in reducing falls in ambulatory care.

Watch and share:

Check out an informative webinar on "Preventing Falls in Ambulatory Care: Strategies for Safer Patient Environments," which discusses the challenges of preve...