Protect patient safety

Legislators should be wary of changing a system that works
March 6, 2012 12:19 pm

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All Pennsylvanians want to improve health care and patient safety. Gov. Tom Corbett's proposal to merge the Patient Safety Authority with the Department of Health may not be the best way to do this.

The authority was established in 2002 as an independent agency under the Medical Care Availability and Reduction of Error Act signed by Gov. Mark Schweiker. It was charged with gathering and analyzing reports of medical errors and near misses, then using that information to reduce the likelihood of mistakes that might harm patients.

The results have been excellent: More than 1.5 million reports have been submitted and hundreds of suggestions for improvements have been issued by the authority and made available on its website,

There are numerous examples of the authority's impact.

By collecting and analyzing data from across the state, the authority discovered why surgeries were sometimes performed on the wrong patients or in the wrong places, thereby helping one group of 30 hospitals reduce these horrible events by 73 percent and a second group go a year with absolutely none.

The authority helped convince the Food and Drug Administration to change labeling requirements for hydromorphone, a powerful narcotic which, when confused with morphine, can cause a fatal overdose.

The authority helped reduce infections from central lines -- catheters used to deliver drugs directly into the heart -- by 24 percent and saw Pennsylvania's rate fall one-third below the national average.

While we assume the authority's work would continue if it becomes part of the health department, such a merger could significantly diminish the authority's effectiveness. It might:

• Weaken reporting of patient safety problems. The governor and Legislature made the Patient Safety Authority independent so it could carry out a nonpunitive, learning-based reporting program that would encourage hospitals to share information on "near miss" events. They believed hospitals would fail to share this information with the health department out of fear that reports would be used for regulatory and enforcement purposes. Instead, the authority treats "near misses" as learning opportunities to encourage better procedures. This technique is used successfully in the airline industry and helps keep travelers safe.

Jeffrey C. Lerner is president and CEO of the ECRI Institute, a nonprofit organization that contracts with the Patient Safety Authority to collect and analyze safety reports (
First Published 2012-03-05 23:23:59

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