Expanding Adverse Event Reporting to Drive Quality Improvement
A statewide advisory committee of the Pennsylvania Patient Safety Authority recently developed a falls reporting program that extended the concept of falls prevention into the realm of quality improvement.1 The resulting Pennsylvania Patient Safety Reporting System (PA-PSRS) uses set definitions of inpatient falls and a falls event decision tree that standardizes falls reporting.2 Hospitals enrolled in the program may access a number of different analytic reports related to inpatient falls from institutions system-wide. A falls dashboard, based on gaps in falls risk assessment processes, and real-time falls outcomes reports, supply data quickly so hospitals can identify areas needing improvement.1,2
A total of 41.3% of hospitals in Pennsylvania enrolled in the program within 6 months of its inception and of these, 82.9% report that the analytic reports were helpful.1 However, the rate of injurious inpatient falls declined less than 1% since introducing the program. Nevertheless, the program’s designers are hopeful that tool will support quality improvement as hospitals adapt to using system-wide data and timely feedback.
1. Gardner LA, Bray PJ, Finley E, et al. Standardizing falls reporting: using data from adverse event reporting to drive quality improvement. J Patient Saf. 2015;September 1, 2015;PMID:26332598.
2. Commonwealth of Pennsylvania Patient Safety Authority. Training manual and users’ guide. Using the Pennsylvania Patient Safety Reporting System (PA-PSRS). Version 6.5, June 2015. https://www.papsrs.state.pa.us/PSA/_pdf/PA-PSRS%20User%20Manual.pdf.