Pennsylvania Patient Safety Authority

The Pennsylvania Patient Safety Authority is an independent state agency located in Harrisburg, Pennsylvania. Its mission is to improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. The Authority was established under Act 13 of 2002, the Medical Care Availability and Reduction of Error (MCARE) Act. It is the only state in the United States to require reporting of both Serious Events (events that harm the patient) and Incidents (near misses). Acute healthcare facilities, including hospitals, ambulatory surgical facilities, birthing centers, and abortion facilities, report events to the Authority. In 2009, the Authority began collecting infection reports from nursing homes. Since its establishment, acute healthcare facilities have reported over 3 million events, and nursing homes have reported over 259,000 events. The Authority identifies problems in the collected data and recommends solutions to promote patient safety. Efforts to improve patient safety in Pennsylvania include education programs, collaborative improvement projects, and the publication of the Pennsylvania Patient Safety Advisory, which highlights significant events and provides information to healthcare facilities.