2020 Pennsylvania Patient Safety Reporting: An analysis of serious events and incidents from the nation’s largest event reporting database

Summary

Pennsylvania is the only state that requires healthcare facilities to report all events that cause harm or have the potential to cause harm to a patient. These patient safety events 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 3.9 million acute care records.

This article, published in Patient Safety, shows details of the PA-PSRS acute care data along with longitudinal and categorical insights that can be used to improve patient safety.

Content

The article concludes with the following key findings:

• There were 278,548 acute care events reported in PA-PSRS during 2020, representing a 5.3% decrease from 2019. 
• Prior to 2020, reports of Incidents and Serious Events had increased each year since 2016.
• The number of reported high harm events has decreased from 726 in 2005 to 417 in 2020. 
• The top four event types, accounting for more than three quarters of the acute event reports in 2020, are:

1. Error Related to Procedure/Treatment/Test
2. Medication Error
3. Complication of Procedure/Treatment/Test
4. and Fall.

• The COVID-19 pandemic appears to have had a direct impact on reporting activity by facilities in 2020.