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What You Need to Know

This newsletter is now biweekly, to better deliver timely information, tools, and resources you can use to keep patients and staff safe. Each issue also includes details about our upcoming events and webinars, as well as stories that highlight the power of event reporting in informing and inspiring change throughout healthcare systems and facilities.

Patient Safety Authority (PSA) staff review reports of unplanned returns to the operating room (OR). Many of these events are incorrectly reported as incidents.

If an injury occurs related to the clinical care of the patient in the healthcare facility—and the patient needs additional healthcare services, including a return to the OR—this is a serious event. 

See an example here.

Planned returns to the OR: For example, a scheduled two-part procedure is not reportable (as an incident or serious event). 

Additionally, if a patient is at higher-than-normal risk of returning to the OR, or if returning to the OR is expected to occur frequently for a particular procedure, this is not reportable. However, the patient must be made aware of this higher risk, and it must be documented.

While failing to report a serious event violates the Medical Care Availability and Reduction of Error (MCARE) Act, submitting nonreportable events into the Pennsylvania Patient Safety Reporting System (PA-PSRS) is also problematic.

Submitting a report when a patient safety event did not occur (e.g., the scheduled two-part procedure) artificially inflates the number of patients returning to the OR. This could make your organization appear less safe than it is—especially if you were asked to produce a raw aggregate list.

Please contact your patient safety liaison if you have ANY questions about whether an event is reportable. 


Pennsylvania hospitals are required to report patient safety events, but do you know why it’s so important? Event reports can be the first indication of underlying problems, regardless of whether harm occurs. They can be tools to trigger widespread change facilitywide—or even nationwide. 

Below is the story of how reporting an event prompted change to improve patient safety throughout a health system.

Root Cause Analysis reveals deeper Medication Reconciliation Issue.

A safety event involving a discharged patient taking too much of a prescribed medication prompted a facility’s liver transplant and clinical leadership teams to perform a root cause analysis. They identified a significant contributing factor to the event: Each transplant service (e.g., lung, liver, etc.) had a different medication reconciliation process upon discharge. Teams from each transplant service and an interprofessional team (including physicians; nurses; pharmacists; advanced practice nurses; Nursing administration and management; case management; and managers from Regulatory, Quality and Patient Safety) collaborated to establish a standardized process for medication reconciliation upon discharge.


Reporting medical errors is a simple but essential way that healthcare workers can improve patient safety, because identifying what went wrong helps prevent it from happening again. One barrier to reporting may be concern about any liability risk for clinicians or facilities. But did you know the law provides a safe space for providers to discuss medical errors?

Charles Kelly, MS, partner, and Samantha Gross, MPH, associate, at Saul Ewing Arnstein & Lehr LLP, will walk you through two important pieces of legislation that protect healthcare workers: the Patient Safety and Quality Improvement Act of 2005, which ensures federal privilege and confidentiality of information about providers and patients involved in a safety event (“Patient Safety Work Product”), and Section 311 of the Medical Care Availability and Reduction of Error Act (MCARE), which exempts investigative materials and documents from discovery or admission as evidence in civil or administrative actions or proceedings.

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

Register now

WEBINAR • 12/13/22 (12:30–1:30 p.m.)

Mitigating Construction Risks in Long-Term Care:

A Blueprint for Infection Preventionists

Amanda Bennett, MPH, infection preventionist at the Patient Safety Authority, will explain the infection preventionists’ role in construction and renovation projects within a healthcare setting, identify common pathogens associated with construction and the infections they cause, describe the requirements and process of performing an Infection Control Risk Assessment (ICRA), and explain infection control mitigation strategies to be used during construction projects.

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

Register now
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