PSA_Logo1_Color - Copy.png

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.

Event Reporting Decision Tree

Pennsylvania made its mark on the patient safety map in 2002 with the passage of the Medical Care Availability and Reduction of Error Act. The first, and still only, state to require the reporting of not only patient safety events that harmed patients, but also near misses, in order to create a learning system across the commonwealth.

The Pennsylvania Patient Safety Reporting System (PA-PSRS) was developed to capture all those patient safety events so that the Patient Safety Authority could advise healthcare facilities about changes they might make to make care safer.

Accurate information is a vital piece of this dynamic system. In 2015, the Patient Safety Authority and the Pennsylvania Department of Health published collaborative guidance to bring a more standardized approach to reporting. Key stakeholders, including the Hospital and Healthsystem Association of Pennsylvania, the Pennsylvania Ambulatory Surgery Association, and the Hospital Council of Western Pennsylvania, were instrumental in developing those guidelines.

The guidelines are incorporated into this decision tree to help patient safety officers determine if an event is reportable and how it should be reported. If you need additional guidance, please reach out to a member of our patient safety liaison team or send an email to

Retained Foreign Objects Are Serious Events

Retained foreign objects, objects that were not intended to be left in a patient and not removed prior to closing the surgical incision, constitute serious events.

The following examples and an abbreviated version of the event reporting decision tree are provided for your reference.

The final sponge count indicated that one sponge was missing. The patient was still in the operating room, but the incision was closed. The surgeon reopened the incision and retrieved the sponge. This is a serious event; see Retained Foreign Object Example 1.

A drill bit broke during orthopedic surgery and the tip became lodged in the patient’s femur. The surgeon decided to leave the drill tip in place because risks associated with removal outweighed the benefits of removal. This is a serious event; see Retained Foreign Object Example 2. Serious events do not necessarily equal inappropriate care. In this case, leaving the broken piece of equipment in the patient was the best care decision, but it still constitutes a serious event.

Retained Foreign Object Example 3 presents an example of a situation in which four sponges were left in a patient intentionally, to be removed later in the operating room before closing the chest. Since this was a planned part of treatment, this is not a serious event.

See Final Guidance for Acute Healthcare Facility Determinations of Reporting Requirements under the Medical Care Availability and Reduction of Error (MCARE) Act, 9b, [44 Pa.B. 6178] [Saturday, September 27, 2014]


Wheelchair-Related Harm

Wheelchairs are one of the most common assistive devices used in healthcare facilities, but improper use can cause a catastrophic injury to patients, visitors, volunteers, or staff.

This alert was prompted by an event reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in 2022 in which a patient’s finger was amputated while opening a wheelchair.

Not knowing how to unfold a wheelchair or where to place your hands when sitting in one can cause injuries such as cuts, loss of nails, broken bones, and even amputation—sometimes affecting more than one digit. Reading and following the owner’s manual before using a wheelchair is one of several ways you can prevent injury to patients and staff.

Download Safety Alert: Wheelchair-Related Harm

Read and share the article “The Hidden Risk of Wheelchair Use” in the September 2022 issue of Patient Safety

Print wheelchair tags alerting patients and staff to the risks

Watch the PSA’s wheelchair safety video


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. Each newsletter will feature similar stories that demonstrate the impact of reporting and give you the information you need to keep patients healthy and safe.

Risk of High-Dose Vitamin C and Inaccurate Glucose Readings

While rounding on a COVID-19 unit, a clinical pharmacy specialist (CPS) participated in a discussion about managing hyperglycemia in a patient who was also receiving high-dose vitamin C. The initial plan was to start an insulin infusion to address the hyperglycemia, but the CPS reminded the team that Accu-Chek values are inaccurate—artificially high or low—in patients receiving high-dose vitamin C and recommended checking a laboratory-drawn glucose value. In this case, the lab draw value result was significantly lower than the Accu-Chek, and an insulin drip was no longer deemed necessary for the patient. Her intervention prevented unnecessary medication and potentially resultant unrecognized hypoglycemia; however, she also reported this event to the hospital’s reporting system to ensure the risk was known systemwide. As a result, computer changes were put into place systemwide to ensure providers are aware of the potential interference of high-dose vitamin C with Accu-Chek results.


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
Facebook            Instagram            LinkedIn            Twitter            YouTube

This communication is intended to support reporting facilities and patient safety programs in their work with the Patient Safety Authority. If you feel you have received this email in error, please contact the PSA before clicking "Unsubscribe" below.