Patient Safety Authority

06/03/2026

Wrong-site surgery (WSS) is defined as a “surgical or other invasive procedure performed on the wrong side, site, or patient, or an incorrect procedure performed on the patient.” WSS has received decades of national and international attention, yet it remains as a persistent, preventable medical error. Pennsylvania mandates that licensed healthcare facilities report patient safety events, ranging from near misses to events resulting in serious harm or death, to the Pennsylvania Patient Safety Reporting System (PA-PSRS). As a result, staff at the Patient Safety Authority have a long history of using patient safety event reports to study WSS, among many other topics.

Read "Wrong-Site Surgery in Dermatology: Report of PA-PSRS Data and Strategies for Prevention":

By Matthew A. Taylor, James S. Taylor. Wrong-site surgery (WSS) is defined as a “surgical or other invasive procedure performed on the wrong side, site, or patient, or an incorrect procedure performed on the patient.”

05/28/2026

The Ebola outbreak highlighted significant gaps in monitoring systems for healthcare professionals. Dynamic health information can be challenging to track and respond to effectively, increasing susceptibility to outbreaks of special pathogens.

Join us on Thursday, June 4, 2026, at 12 p.m. EDT for a free webinar: "Operationalizing Biopreparedness: Digital Healthcare Worker Monitoring for Ebola and Other Special Pathogens."

Three leaders from NYC Health + Hospitals, Syra Madad, Andrew Vegoda, and Dr. Andrew Wallach, will

• Describe operational challenges in post-exposure monitoring for Ebola and other special pathogens
• Explain how digital monitoring tools can strengthen healthcare workers’ safety
• Identify key design considerations for special pathogen monitoring systems
• Discuss how Ebola preparedness lessons can be applied to other special pathogens
• Evaluate how drills and simulations validate readiness; reveal near misses; test escalation pathways; improve coordination between occupational health, infection prevention, supervisors, emergency management, and public health; and recognize the importance of human oversight in digital preparedness systems

The Patient Safety Authority has approved this activity for 1.0 AMA PRA Category 1 Credit(s) for physicians and nursing contact hours.

Register now: cb3265d2-3968-43ab-8d03-31e1f85e0a36@418e2841-0128-4dd5-9b6c-47fc5a9a1bde" rel="ugc" target="_blank">https://events.gcc.teams.microsoft.com/event/cb3265d2-3968-43ab-8d03-31e1f85e0a36@418e2841-0128-4dd5-9b6c-47fc5a9a1bde

05/21/2026

In Pennsylvania, licensed healthcare facilities are required to report all events that cause harm or have the potential to cause harm to a patient. The reports are captured in the Pennsylvania Patient Safety Reporting System (PA-PSRS) and then the Patient Safety Authority (PSA) analyzes them to identify causes or trends and share strategies to prevent harm. With over 5.8 million reports dating back to 2004, PA-PSRS is one of the largest data repositories of its kind in the world.

Each year, PSA publishes an analysis of the acute and ambulatory care reports submitted to PA-PSRS, and this article expands on that work by highlighting the serious events reported to PA-PSRS with the Medication Error event type in 2025.

Read more in PATIENT SAFETY:

By Myungsun Ro. In 2025, 82 facilities submitted a total of 303 serious Medication Error events to PA-PSRS.

05/11/2026

Just published:

Patients undergoing ambulatory surgery are typically discharged on the day of the procedure, but psychomotor impairment from sedative and anesthetic drugs may linger and prevent them from safely driving or walking home. Current regulations, accreditation standards, and professional guidelines continue to require that patients be accompanied by a responsible adult following anesthesia or sedation; however, some patients may not be able to arrange an es**rt, leading to procedure delays and cancellations, and highlighting barriers to healthcare access. This manuscript details contemporary evidence, regulatory expectations, and risk-reduction strategies. The identified literature provides limited information to facilitate evidence-based decision-making for unaccompanied discharge after ambulatory surgery; however, the literature offers important considerations and contextual information to support decision-making.

Read more in PATIENT SAFETY:

By Anna Thomas, Jackie Ferenschak. Patients undergoing ambulatory surgery are typically discharged on the day of the procedure, but psychomotor impairment from sedative and anesthetic drugs may linger and prevent them from safely driving...

05/05/2026

Join us tomorrow at noon for a free webinar: "Stopping the Spread: Preventing MDROs in Long-Term Care."

Multidrug-resistant organisms (MDROs) continue to be a major concern in healthcare. Teams often struggle to understand how MDROs spread in their specific settings and how to best reduce that risk.

Join Lana Mason, MPH, RN, infection prevention advisor at the Patient Safety Authority, for a webinar titled “Stopping the Spread: Preventing MDROs in Long-Term Care.” This webinar will recognize common ways MDROs are spread in long-term care, describe practices that reduce their spread, and identify possible failures in current practices related to equipment cleaning and use.

1.0 continuing education hours will be awarded for completion of this course. Continuing education credits apply to Pennsylvania registered nurses only.

Register now: 56bc067e-df8a-43e6-b38d-b9dc3e877184@418e2841-0128-4dd5-9b6c-47fc5a9a1bde" rel="ugc" target="_blank">https://events.gcc.teams.microsoft.com/event/56bc067e-df8a-43e6-b38d-b9dc3e877184@418e2841-0128-4dd5-9b6c-47fc5a9a1bde

04/30/2026

We are pleased to share the Patient Safety Authority's 2025 Annual Report, highlighting our ongoing efforts to improve healthcare in Pennsylvania: https://patientsafety.pa.gov/PatientSafetyAuthority/Pages/2025-annual-report.aspx

PSA's accomplishments last year include:

• We introduced virtual office hours with PSA infection prevention advisors to discuss preventing the spread of diseases in long-term care facilities and share information and experiences.

• We applied for Joint Accreditation, which extends our ability to provide continuing education credits to physicians and pharmacists (in addition to nurses).

• We published a dozen articles leveraging data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), such as "New Research Shows Discharge Window as High-Risk Period for Patient Falls" and "Strategies to Prevent Five-Fold Wrong Dose Errors With U-500 Insulin." These were distributed in our monthly newsletter and reprinted in our peer-reviewed journal, PATIENT SAFETY, which reaches over 234,800 global readers.

• We continued to advance the goals of our five-year strategic plan, Reimagine Patient Safety 2029. Completed actions include assembling a statewide patient safety advisory panel, distributing resources to the patient outreach network to raise awareness and understanding of safe healthcare, and taking steps to establish a component patient safety organization.

With over 5.8 million reports, PA-PSRS is the largest patient safety data repository of its kind in the United States and among the largest in the world. Read the full analysis of PA-PSRS data from 2025 in PATIENT SAFETY: https://patientsafetyj.com/

04/29/2026

JUST PUBLISHED: In conjunction with the Patient Safety Authority’s 2025 annual report, PSA took a close look at the 30,967 healthcare-associated infections (HAIs) reported last year by long-term care facilities (e.g., nursing homes) to the Pennsylvania Patient Safety Reporting System (PA-PSRS). The total number of infection reports was a 16.9% increase from 2024 to 2025—the fourth consecutive annual increase—and the overall infection rate (1.25 infections per 1,000 resident days) was a 15.7% increase from the previous year, attributed to rising rates across all infection types, excluding device-related bloodstream infections. Of these, there were notable increases in respiratory tract infections, primarily due to a 117.7% increase in influenza reports, and gastrointestinal infections, which included an 84.7% increase in norovirus.

Read this article for free in PATIENT SAFETY:

By Shawn Kepner, Denise Cutting & 1 more. In 2025, the number of infection reports submitted to PA-PSRS and the overall infection rate increased, due to a rise in all infection types except for device-related bloodstream infections.

04/28/2026

JUST PUBLISHED: In conjunction with the Patient Safety Authority’s 2025 annual report, PSA took a close look at the 326,672 incidents and serious events reported last year by hospitals, ambulatory surgical facilities (ASFs), birthing centers, and abortion facilities to the Pennsylvania Patient Safety Reporting System (PA-PSRS). The total number of reports increased 3.6% from 2024 to 2025, while preliminary reporting rates for hospitals (32.0 reports per 1,000 patient days) and ASFs (10.9 reports per 1,000 surgical encounters) decreased by 0.5 points from 2024. This comprehensive review and analysis of 2025 PA-PSRS reports may indicate that year-to-year changes can be attributed to variations in reporting rather than broader shifts. PSA will continue to work with Pennsylvania healthcare facilities to enhance the quality of event reporting.

Read the article for free in PATIENT SAFETY:

By Shawn Kepner, Rebecca Jones. In conjunction with the Patient Safety Authority’s 2025 annual report, PSA took a close look at the 326,672 incidents and serious events reported last year by hospitals, ambulatory surgical facilities...

04/16/2026

Congratulations to Patient Safety Authority Board Chair Dr. Nirmal Joshi on being named a 2026 Health Care Hero!

Central Penn Business Journal’s annual Health Care Heroes Awards recognize excellence, promote innovation, educate on healthcare issues, and honor individuals and organizations for their significant impact on healthcare quality in Central Pennsylvania. At their awards breakfast on April 9 in Harrisburg, CPBJ honored Dr. Joshi as a Physician of the Year, in recognition of his generosity, compassionate care, and commitment to improving people’s lives.

Dr. Joshi has dedicated his life and career to helping others: providing a free health clinic and education through the Joshi Health Foundation, mentoring young physician leaders at the Pennsylvania Medical Society, and guiding PSA’s efforts to quantify and reduce medical error in the commonwealth—just a few of his many humble achievements.

Please join us in celebrating and thanking Dr. Joshi for all he does to make the world a better place!

04/15/2026

Just published: Evidence-based medicine strengthens decision-making, but contemporary care—including clinical artificial intelligence (AI)—often operates under uncertainty, heterogeneous patient contexts, and shifting performance. A common failure mode is committing too early to actions that are difficult to reverse, monitor, or repair.

Evidence-steered medicine (ESM) structures decisions as controlled microsteps: (1) a brief support check, (2) uncertainty banding that constrains action strength, (3) a low-dose action grammar prioritizing reversible micro-interventions paired with short-horizon readouts, and (4) reason-coded governance that enables auditability, learning, and rapid de-escalation/repair. The model yields measurable predictions on severe safety events, recoverability (checkpointing and de-escalation pathways), time to detection of unsafe trajectories, learning efficiency from reason-code distributions, and (in AI workflows) automation-bias and drift-trigger events.

ESM complements evidence-based medicine by making uncertainty operational: It specifies how to act safely when evidence is incomplete. The hypotheses can be evaluated using retrospective replay, prospective pilots, and stepped-wedge rollouts without replacing standard of care.

Read more for free in PATIENT SAFETY:

By Konstantin Gurbanov. Evidence-based medicine strengthens decision-making, but contemporary care—including clinical artificial intelligence (AI)—often operates under uncertainty, heterogeneous patient contexts, and shifting performance.