Pennsylvania pioneers mandatory near-miss reporting for hospitals

Nurse Leader Insider, June 4, 2007

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Near-miss reporting provides rich information that could potentially reduce adverse events, yet only one state in the country, Pennsylvania, requires it. And even though most hospitals encourage staff to alert them to close calls, many clinicians are loath to do so for fear of reprisal.

"I still think there's a reluctance, because they're saying, 'Well, nothing bad happened, so why do we need to report them?' " says Karen Griffin, RN, MSN, CNAA, a director of the American Academy of Ambulatory Care Nursing.

There are plenty of reasons to report near-misses, according to the Pennsylvania Patient Safety Authority.

"The causes of adverse events are generally the same things that cause near-misses, so ideally, if you're looking at reports of near-misses, you're looking at the causes of those things to prevent adverse events before they actually occur," says Bill Marella, project manager of the Pennsylvania Patient Safety Reporting System. Pennsylvania has required all healthcare organizations to report near-misses since June 2004. The names of the clinicians and patients involved are kept anonymous.

The organization also distributes articles and advisories to Pennsylvania hospitals and ambulatory surgical facilities and makes them available on its Web site. The articles feature serious events and incidents (i.e., near-misses) that have actually occurred in Pennsylvania facilities. Guidelines are offered to help hospitals implement change in their facilities and prevent further occurrences. The authority recently queried patient safety officers about how many changes they had implemented in their facilities as result of reading the advisories. The response: More than 500 policy and process modifications had been made by the patient safety officers after reading the authority's articles.

The Patient Safety Authority's success has not gone unnoticed. The Joint Commission and the National Quality Forum named the authority the recipient of the John M. Eisenberg Award for advancing patient safety in 2006.

When the program first began, some hospitals were a little leery of the Patient Safety Authority, as it was a new organization.

"But I think that we've shown them that it's not our role to be punitive," Marella says. "We are not a regulatory agency. We are a learning agency. I think that they really believe that our hearts and minds are in the right place in terms of making their facilities safer."

Editor's note: For more information about Pennsylvania's Patient Safety Authority, go to

Source: Quality Improvement Report, May 2007, HCPro. Inc.

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