Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems.

Background: In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems.

Methods: We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database.

Standardizing Falls Reporting: Using Data From Adverse Event Reporting to Drive Quality Improvement.

Objective: To enhance the value of the Pennsylvania Patient Safety Reporting System (PA-PSRS) falls reports by developing a falls reporting program that standardizes falls reporting and provides timely benchmarked falls rates and process measurement reports hospitals can use to identify areas of improvement in their falls program.

Methods: The new PA-PSRS falls reporting program requires adherence to standardized definitions of falls to generate standardized, customizable analytic reports. An advisory committee and statewide survey guided the development of the program, data definitions, system features and functionality, and methods for stratifying reporting criteria.

Screening Electronic Health Record-Related Patient Safety Reports Using Machine Learning.

Introduction: The objective of this study was to develop a semiautomated approach to screening cases that describe hazards associated with the electronic health record (EHR) from a mandatory, population-based patient safety reporting system.

Methods: Potentially relevant cases were identified through a query of the Pennsylvania Patient Safety Reporting System. A random sample of cases were manually screened for relevance and divided into training, testing, and validation data sets to develop a machine learning model.

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.

Background: External reporting of medical errors a adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most frequently cited product classes involved in harmful medication errors, would be captured in a variety of patient safety reporting programs.

Methods: Data on reported errors involving the anticoagulant heparin were reviewed, compared, and aggregated from the databases of three large patient safety reporting programs-MEDMARX, the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, and the University Health System Consortium, together representing more than 1,000 reporting organizations for 2005

Results: Approximately 300,000 medication errors and near misses were reported to the programs, and 10,359-a mean of 3.

The role for leaders of health care organizations in patient safety.

We review what leaders of health care systems, including chief executive officers and board members, need to know to have "patient safety literacy" and do to make their systems safe. High reliability organizations produce reliable results that are not dependent on providers being perfect. Their characteristics include the commitment of leadership to safety as a system responsibility, with a culture of safety that decreases variability with standardized care and does not condone "at-risk behavior.

Translating patient safety legislation into health care practice.

Background: An independent state agency, the Authority is charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM (PA-PSRS): The Authority implemented PA-PSRS, a mandatory reporting and analysis system for both adverse events and near-misses, among 450 hospitals, birthing centers, and ambulatory surgical facilities. Pennsylvania is the only state to require the reporting of both adverse events and near-misses.

A surgeon who CARES can be safer.

The characteristics of a high-reliability organization are reviewed. Examples of how these characteristics relate to patient safety in surgical practice are illustrated by vignettes. The characteristics discussed include commitment to safety demonstrated to others by the conduct of one's practice; attention focused on one's own performance and the performance of others to the task at hand; rehearsal and proper preparation and contingency planning for procedures; effective communication so that information is accurate, adequate, unambiguous, and confirmed; and sense-making, or an understanding and verification of consistency between what is observed and expected and between what is planned and the premises for those plans.