Patient Safety Trends in 2022: An Analysis of 256,679 Serious Events and Incidents From the Nation’s Largest Event Reporting Database

• Published in: Patient safety (Harrisburg, Pa. Online) Vol. 5; no. 2
• Main Authors: Kepner, Shawn, Jones, Rebecca
• Format: Journal Article
• Language: English
• Published: Patient Safety Authority 28.04.2023
• ISSN: 2689-0143; 2641-4716
• DOI: 10.33940/001c.74752

Background Pennsylvania is the only state that requires acute care facilities to report all events of harm or potential for harm. The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world, with over 4.5 million acute care event reports dating back to 2004. Herein, we examine patient safety event reports submitted to the PA-PSRS acute care database in 2022 and compare them to prior years. Methods We extracted data from PA-PSRS and obtained data from the Pennsylvania Health Care Cost Containment Council (PHC4). Counts of reports were calculated based on report submission date, and rates were calculated based on event occurrence date and calculated per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs). Results A total of 256,679 reports were submitted to PA-PSRS in 2022, representing an 11.1% decrease from 2021. Three facilities collectively submitted 18,601 fewer reports in 2022 compared to 2021, which accounted for 57.8% of the overall decrease. Reports of serious and high harm events increased by 7.7% and 11.1%, respectively. Of the 256,679 reports submitted, 95.9% were from hospitals, 3.9% were from ambulatory surgical facilities, and 0.2% were from birthing centers and abortion facilities. The vast majority of the 2022 reports were incidents (96.2%) as opposed to serious events (3.8%). For each of the past five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, accounting for 32.8% of all submitted acute care event reports in 2022. The second, third, and fourth most frequently reported event types in 2022 were Complication of Procedure/Treatment/Test, Medication Error, and Fall, accounting for 15.6%, 13.2%, and 12.8% of submitted reports, respectively. The reported event rate based on occurrence date for hospitals in the first half of 2022 was 27.5 reports per 1,000 patient days. For ASFs, the reported event rate for the first half of 2022 was 9.4 reports per 1,000 surgical encounters. Conclusions There was a decrease in the number of incident reports submitted to PA-PSRS in 2022 and an increase in serious and high harm event reports. PSA will continue to work with facilities, monitor reporting, and take further action as needed.