Patient Safety Trends in 2021:
An Analysis of 288,882 Serious Events and Incidents
F
rom the Nation’s Largest Event Reporting Database
By Shawn Kepner, MS*
◆
& Rebecca Jones, MBA, RN
◆
DOI: 10.33940//data/2022.6.2
Submitted: April 5, 2022 / Accepted: April 5, 2022
Background: Pennsylvania is the only state that requires
acute care facilities to report all events of harm or potential
for harm. With over 4.2 million acute care event reports, 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. This study exam-
ines patient safety event reports submitted to the PA-PSRS
acute care database in 2021.
Methods: We queried PA-PSRS for all event reports submit-
ted by Pennsylvania acute care facilities during calendar
year 2021. We also obtained the most current data from
the Pennsylvania Health Care Cost Containment Council
(PHC4) to calculate rates based on patient days for hospitals
and surgical encounters for ambulatory surgical facilities
(ASFs). For the Other (specify) subtype within the Other/
Miscellaneous event type, we identied the words occur-
ring most frequently in the required free-text response
eld and calculated the increase in associated reports for
each of the words from 2020 to 2021.
Results: Of the 288,882 patient safety event reports sub-
mitted by Pennsylvania’s acute care facilities in 2021,
96.8% were from hospitals and 3.1% were from ASFs.
The remaining 0.1% were from birthing centers and abor-
tion facilities. The vast majority of the 2021 reports were
Incidents (96.9%) rather than Serious Events (3.1%). For
each of the past ve years, the most frequently reported
event type was Error Related to Procedure/Treatment/
Test, accounting for 31.3% of all submitted acute care
event reports in 2021. The second, third, and fourth most
frequently reported event types were Medication Error,
Complication of Procedure/Treatment/Test, and Fall,
accounting for 16.9%, 15.3%, and 12.3% of submitted
reports in 2021, respectively. The reporting rate for hospi-
tals in 2021 (Q1 and Q2) was 30.9 reports per 1,000 patient
days. For ASFs, the reporting rate in 2021 (Q1 and Q2) was
8.6 reports per 1,000 surgical encounters.
Conclusions: There was an increase in the total number
of patient safety event reports submitted in 2021, yet the
percentage of high harm reports remained steady. Four
event types—Error Related to Procedure/Treatment/Test,
Medication Error, Complication of Procedure/Treatment/
Test, and Fall—accounted for more than three-quarters of
all reports submitted to PA-PSRS in 2021. Readers can use
the longitudinal and categorical insights shared in this
article to focus patient safety improvement eorts.
Keywords: acute care, patient safety, event reports, annual
report, incidents, serious events, reporting rates, fall rates,
COVID-19
*Corresponding author
Patient Safety Authority
Disclosure: The authors declare that they have no relevant or material financial interests.
18 I PatientSafetyJ.com I Vol. 4 No. 2 I June 2022
Introducon
P
ennsylvania is the only state that requires health-
care facilities to report all events that cause harm
or have the potential to cause harm to a patient.
These patient safety events are reported to the
Pennsylvania Patient Safety Reporting System (PA-PSRS)
a
,
which is the largest repository of patient safety data in the
United States and one of the largest in the world, with over
4.2 million acute care records.
This article provides details from the PA-PSRS acute care
reports submitted in 2021, along with longitudinal and
categorical insights that can be used to improve patient safety.
Denions
Terms describing patient safety occurrences, including
“serious event,” “medical error,” “adverse event,” “harm,”
and “incident,” are oen used interchangeably. However,
within the context of this manuscript they have distinct
meanings and indications for whether they must be
reported to PA-PSRS in accordance with the Medical Care
Availability and Reduction of Error (MCARE) Act (Act 13 of
2002).
1
An “incident” is dened as “an event, occurrence,
or situation involving the clinical care of a patient in a
medical facility which could have injured the patient but
did not either cause an unanticipated injury or require the
delivery of additional healthcare services to the patient.”
1
A “serious event” is dened as “an event, occurrence, or
situation involving the clinical care of a patient in a med-
ical facility that results in death or compromises patient
safety and results in an unanticipated injury requiring the
delivery of additional healthcare services to the patient.”
1
Each event report includes a harm score—assigned by
the reporting facility—that describes the potential or
actual harm to the patient resulting from the event.
Table 1 lists the definition for each harm score, along
with harm score groupings for incidents, serious events,
and high harm events.
Methods
We extracted reports from PA-PSRS on January 18, 2022, to
include all reports submitted during calendar year 2021.
We also obtained data from the Pennsylvania Health Care
Cost Containment Council (PHC4)
b
to calculate rates based
a
PA-PSRS is a secure, web-based system through which Pennsylvania hospitals, ambulatory surgical facilities, abortion facilities, and birthing centers submit
reports of patient safety–related incidents and serious events in accordance with mandatory reporting laws outlined in the Medical Care Availability and
Reduction of Error (MCARE) Act (Act 13 of 2002).
1
All reports submitted through PA-PSRS are condential and no information about individual facilities or
providers is made public.
b
The Pennsylvania Health Care Cost Containment Council (PHC4) is an independent state agency responsible for addressing the problem of escalating
health costs, ensuring the quality of healthcare, and increasing access to healthcare for all citizens regardless of ability to pay. PHC4 has provided data to
this entity in an eort to further PHC4’s mission of educating the public and containing healthcare costs in Pennsylvania. PHC4, its agents, and its sta
have made no representation, guarantee, or warranty, express or implied, that the data—nancial-, patient-, payor-, and physician-specic information—
provided to this entity are error-free, or that the use of the data will avoid dierences of opinion or interpretation. This analysis was not prepared by PHC4.
This analysis was done by the Patient Safety Authority. PHC4, its agents, and its sta bear no responsibility or liability for the results of the analysis, which
are solely the opinion of this entity.
on patient days for hospitals and surgical encounters for
ambulatory surgical facilities (ASFs). The most current
data from PHC4 was for Q2 2021, which allowed us to
calculate 2021 reporting rates using half of the year’s data.
We performed a descriptive analysis based on information
provided in the structured and unstructured data elds
of the PA-PSRS reports. For the Other (specify) subtype
within the Other/Miscellaneous event type, we looked at
the words occurring most frequently in the required free-
text response eld. From there, we calculated the increase
in associated reports for each of the words from 2020 to
2021. Specically, the 5,000 most frequent words were
passed back through the data to determine how many
reports were aected, as one report could have had sev-
eral occurrences of the same word. Excluded from the
nal analysis were entries of punctuation with no words
(e.g., “…”) and uninformative common words—often
referred to as stop words—such as a, an, on, the, and up.
In addition, if a single facility made up 50% or more of
the increase in number of reports from 2020 to 2021 for a
particular word, the word was excluded due to concerns
of overrepresentation.
For our analysis related to the eects of the COVID-19 pan-
demic, there are two monthly charts showing report counts
based on event date instead of submission date. We chose
to use the event date to show when events were occurring
relative to pandemic peaks, rather than when reports were
submitted. We performed this extract on April 13, 2022,
to ensure capture of the most current and complete data
prior to publication.
Results
A total of 288,882 reports were submitted by Pennsylvania
acute care facilities in 2021, of which 9,042 were serious
events, and of those serious events, 442 were classied as
high harm (see Figure 1). The numbers of total reports,
serious events, and high harm events increased in 2021
compared to 2020, with increases of 3.7%, 8.1%, and 6.0%,
respectively.
Incidents and serious events expressed as a percentage
of reports are shown in Figure 2. Consistently, incidents
comprise approximately 97% of reports and serious
events comprise approximately 3%.
Paent Safety I Vol. 4 No. 2 I June 2022 I 19
20 I PatientSafetyJ.com I Vol. 4 No. 2 I June 2022
Harm Score Denion
A Circumstances that could cause adverse events
B1 An event occurred but it did not reach the individual
B2
An event occurred but it did not reach the individual because of acve
recovery eorts by caregivers
C
An event occurred that reached the individual but did not cause
harm and did not require increased monitoring
D
An event occurred that required monitoring to conrm that it resulted in
no harm and/or required intervenon to prevent harm
E
An event occurred that contributed to or resulted in temporary
harm and required treatment or intervenon
F
An event occurred that contributed to or resulted in temporary
harm and required inial or prolonged hospitalizaon
G An event occurred that contributed to or resulted in permanent harm
H
An event occurred that resulted in a near-death event (e.g., required
ICU care or other intervenon necessary to sustain life)
I An event occurred that contributed to or resulted in death
Incidents
Serious Events
High Harm
Table 1. PA-PSRS Harm Scores
Figure 1. Total Reports, Serious Events, and High Harm Events Submied to PA-PSRS
300k
250k
200k
150k
100k
50k
0
Total Reports
16k
14k
12k
10k
8k
6k
4k
2k
0
Serious Events
1800
1600
1400
1200
1000
800
600
400
200
0
High Harm Events
2005 2007 2009 2011 2013 2015 2017 2019 2021
169,069
726
7,502
288,882
442
9,042
Paent Safety I Vol. 4 No. 2 I June 2022 I 21
Figure 2. Incidents and Serious Events as a Percentage of Total Submied PA-PSRS Reports
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
% of Total Reports
Incidents Serious Events
95.6% 96.5% 96.6% 96.1% 96.4% 96.7% 96.5% 96.6% 96.9% 97.1% 96.8% 97.0% 97.1% 97.2% 97.1% 97.0% 96.9%
4.4% 3.5% 3.4% 3.9% 3.6% 3.3% 3.5% 3.4% 3.1% 2.9% 3.2% 3.0% 2.9% 2.8% 2.9% 3.0% 3.1%
Table 2. Number and Percentage of Reports Submied to PA-PSRS by Facility Type and Event Classicaon
Facility
Type
Event
Classicaon
Number of Reports % of Total Reports
2019 2020 2021 2019 2020 2021
Hospital
Incident 278,213 263,997 272,469 94.6% 94.8% 94.3%
Serious Event 6,698 6,726 7,109 2.3% 2.4% 2.5%
Subtotal 284,911 270,723 279,578 96.9% 97.2% 96.8%
Other Acute
Care Facilies
Incident 7,367 6,169 7,371 2.5% 2.2% 2.6%
Serious Event 1,897 1,638 1,933 0.6% 0.6% 0.7%
Subtotal 9,264 7,807 9,304 3.1% 2.8% 3.2%
Totals
Incident 285,580 270,166 279,840 97.1% 97.0% 96.9%
Serious Event 8,595 8,364 9,042 2.9% 3.0% 3.1%
Total 294,175 278,530 288,882 100.0% 100.0% 100.0%
Note: Other Acute Care Facilies include ambulatory surgical facilies, birthing centers, and aboron facilies. Also, numbers shown for prior years may dier from
previously published numbers due to subsequent report deleons or classicaon changes made by reporng facilies.
Table 2 shows a breakdown of Incidents and Serious Events by facil-
ity type from the past three years. Hospitals and the group of other
acute care facilities (ASFs, birthing centers [BRCs], and abortion
facilities [ABFs]) had increases in the number of reports submitted
in 2021 compared to 2020. The proportion of reports from other
acute care facilities increased from 2.8% in 2020 to 3.2% in 2021.
The distribution of reports by harm score submitted during years 2019–
2021 is shown in Table 3. Consistently, the most frequent harm score
is C (39.4% in 2021), followed by harm scores D, B2, and A. Serious
events comprised 3.1% of all reports in 2021, with harm scores E and
F being reported most frequently. Also, while serious events increased
from 2020 to 2021 by 8.1%, harm score I (indicating a patient death)
decreased by 5.3%.
Reporng Rates
In addition to examining increases or decreases in the number of
reports, we can use normalized data (e.g., rates) to assess changes
in reporting based on patient days for hospitals and surgical
encounters for ASFs. Figure 3 shows that the 2021 reporting rate
for hospitals through Q2 2021 dropped below the rates for 2019
and 2020; for ASFs, the 2021 reporting rate through Q2 2021 is
similar to the rate in 2020 (8.6 and 8.8, respectively).
Event Types
Each PA-PSRS report includes an event type and subtype(s) that are
assigned by the reporting facility. The reporting taxonomy for inci-
dents and serious events provides for 10 main event types, with 228
possible combinations of event type and subtype(s). Table 4 shows
the number of reports for each event type over the past ve years.
For each of the past ve years, the top four most frequently reported
event types have remained consistent: Error Related to Procedure/
Treatment/Test (P/T/T), Medication Error, Complication of P/T/T,
and Fall. In 2021, Error Related to P/T/T accounted for 31.3% of all
reports, while Medication Error, Complication of P/T/T, and Fall
accounted for 16.9%, 15.3%, and 12.3%, respectively.
From a distribution perspective, the greatest increase in percentage
of reports in 2021 compared to 2020 occurred with event type Other/
Miscellaneous, which increased by 1.3 percentage points, from
8.3% of reports in 2020 to 9.6% in 2021. The second greatest increase
occurred with event type Fall, which represented 11.8% of reports
in 2020 and 12.3% in 2021, an increase of 0.5 percentage points.
The greatest decrease in percentage of reports in 2021 compared
to 2020 occurred with event type Complication of P/T/T, going
from 16.2% in 2020 to 15.3% in 2021. The second greatest decrease
occurred with event type Error Related to P/T/T, which went from
32.1% of reports in 2020 to 31.3% in 2021.
22 I PatientSafetyJ.com I Vol. 4 No. 2 I June 2022
Table 3. Number and Percentage of Reports Submied to PA-PSRS by Harm Score With Change in Reports From 2020 to
2021
Number of Reports % of Total Reports Change in Reports 2020–2021
Harm Score 2019 2020 2021 2019 2020 2021 Number Percent
A 26,930 27,563 28,003 9.2% 9.9% 9.7% 440 1.6%
B1 3,835 2,803 2,772 1.3% 1.0% 1.0% -31 -1.1%
B2 39,208 34,100 35,874 13.3% 12.2% 12.4% 1,774 5.2%
C 119,728 112,976 113,685 40.7% 40.6% 39.4% 709 0.6%
D 95,879 92,724 99,506 32.6% 33.3% 34.4% 6,782 7.3%
Incidents -
Subtotal
285,580 270,166 279,840 97.1% 97.0% 96.9% 9,674 3.6%
E 5,846 5,863 6,330 2.0% 2.1% 2.2% 467 8.0%
F 2,329 2,084 2,270 0.8% 0.7% 0.8% 186 8.9%
G 57 56 66 0.0% 0.0% 0.0% 10 17.9%
H 116 115 143 0.0% 0.0% 0.0% 28 24.3%
I 247 246 233 0.1% 0.1% 0.1% -13 -5.3%
Serious Events -
Subtotal
8,595 8,364 9,042 2.9% 3.0% 3.1% 678 8.1%
Total 294,175 278,530 288,882 100.0% 100.0% 100.0% 10,352 3.7%
Note: Numbers shown for prior years may dier from previously published numbers due to subsequent report deleons or harm score changes made by reporng
facilies.
Paent Safety I Vol. 4 No. 2 I June 2022 I 23
Figure 3. PA-PSRS Reporng Rates for Hospitals (Reports per 1,000 Paent Days) and ASFs (Reports per 1,000 Surgical
Encounters)
Reporting Rate
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
23.5
29.7
30.5
32.7
30.9
27.6
25.8
24.8
24.0
5.3
8.3
8.4
8.9
8.6
7.8
7.2
6.3
5.3
Hospitals
ASFs
(Q1 & Q2)
32.3
8.8
Note: The 2021 reporng rate is based on Q1 and Q2 only, due to lagged data related to paent days and surgical encounters. Also, rates for prior years may dier
from previously published rates due to subsequent changes made by reporng facilies.
Table 4. Number and Percentage of Reports Submied to PA-PSRS by Event Type in Descending Order by 2021 Frequency
Number of Reports % of Total Reports
Event Type 2017 2018 2019 2020 2021 2017 2018 2019 2020 2021
Error Related to P/T/T 80,103 89,154 96,440 89,335 90,452 29.5% 31.4% 32.8% 32.1% 31.3%
Medicaon Error 48,546 51,979 52,884 46,559 48,715 17.9% 18.3% 18.0% 16.7% 16.9%
Complicaon of P/T/T 40,661 43,202 46,691 45,180 44,132 15.0% 15.2% 15.9% 16.2% 15.3%
Fall 34,041 33,657 31,978 32,775 35,602 12.5% 11.8% 10.9% 11.8% 12.3%
Other/Miscellaneous 24,467 23,139 22,761 23,190 27,707 9.0% 8.1% 7.7% 8.3% 9.6%
Skin Integrity 24,131 21,752 20,546 19,697 20,601 8.9% 7.6% 7.0% 7.1% 7.1%
Equipment/Supplies/
Devices
7,092 7,805 8,792 8,062 7,806 2.6% 2.7% 3.0% 2.9% 2.7%
Adverse Drug Reacon 5,669 5,958 5,700 5,624 5,868 2.1% 2.1% 1.9% 2.0% 2.0%
Transfusion 5,017 5,264 6,195 5,779 5,648 1.8% 1.9% 2.1% 2.1% 2.0%
Paent Self-Harm 2,136 2,439 2,188 2,329 2,351 0.8% 0.9% 0.7% 0.8% 0.8%
Total 271,863 284,349 294,175 278,530 288,882 100% 100% 100% 100% 100%
Note: Numbers shown for prior years may dier from previously published numbers due to subsequent report deleons or event type changes made by reporng
facilies.
Serious Events
The number and percentage of serious events submitted for
each event type for the past ve years are shown in Table 5. In
2021, Complication of P/T/T represented 15.3% of reports, yet it
accounted for the majority (54.2%) of serious events. Similar to
its increase in percentage of all reports, Other/Miscellaneous
also showed the greatest increase in percentage of serious events
from 2020 to 2021, increasing from 8.5% in 2020 to 9.4% in 2021.
Event Subtypes
Each of the 10 event types has between 6 and 13 subtypes to fur-
ther classify the event. The total number of reports and serious
events, as well as their associated percentage distributions, are
shown in Table 6. This is a detailed accounting of reports submit-
ted in 2021 by the rst level of subtype for each event type. The
event types in the le column are listed in descending order by the
number of reports (i.e., the same ordering as Table 4). Within each
event type, the subtypes are listed in descending order as well.
Subtype Distribution Changes for All Reports
The event subtype Other (specify) within the Other/Miscellaneous
event type had the largest increase in its percentage of reports,
going from 5.2% in 2020 to 6.3% in 2021. This event subtype also
had the largest increase in number of reports from 2020 to 2021,
with an increase of 3,863.
Subtype Distribution Changes for Serious Events
The Healthcare-Associated Infection subtype of Complication of
P/T/T had the greatest increase in its representative percentage of
serious events from 2020 to 2021, going from 5.1% in 2020 to 6.2%
in 2021. The greatest decrease in percentage was the IV site com-
plication (phlebitis, bruising, inltration) subtype of Complication
of P/T/T, which went from 4.3% of all serious events in 2020 to
3.3% of all serious events in 2021.
Other/Miscellaneous - Other
The most undened portion of the event type taxonomy is the
Other (specify) subtype within the Other/Miscellaneous event
type. As shown in Table 6, this event subtype accounted for 18,231
of 288,882 (6.3%) reports in 2021. Also, as mentioned above, this
subtype had the greatest increase in its representative percent-
age of all reports from 2020 to 2021. Therefore, it is important to
investigate this event type and subtype combination.
We performed a word frequency tabulation based on responses
in the mandatory free-text eld used to describe reports submit-
ted using the Other (specify) event subtype. As described in our
methods, we excluded words that were inherently uninformative
or that were overrepresented by a single facility. This process
was completed for 2020 and 2021, and the increase in number
of reports was calculated. Table 7 shows the top 20 words with
respect to increase in associated reports from 2020 to 2021. The
words “response” and “delay” had the largest increase from 2020
to 2021.
Table 5. Number and Percentage of Serious Events Submied to PA-PSRS by Event Type in Descending Order by 2021
Frequency
Number of Serious Events % of Total Serious Events
Event Type 2017 2018 2019 2020 2021 2017 2018 2019 2020 2021
Complicaon of P/T/T 4,138 4,183 4,529 4,577 4,905 52.5% 51.7% 52.7% 54.7% 54.2%
Fall 945 961 932 940 1,045 12.0% 11.9% 10.8% 11.2% 11.6%
Other/Miscellaneous 818 799 983 708 848 10.4% 9.9% 11.4% 8.5% 9.4%
Error Related to P/T/T 688 705 768 753 730 8.7% 8.7% 8.9% 9.0% 8.1%
Skin Integrity 607 779 654 575 612 7.7% 9.6% 7.6% 6.9% 6.8%
Adverse Drug Reacon 243 217 241 344 430 3.1% 2.7% 2.8% 4.1% 4.8%
Medicaon Error 201 188 182 166 172 2.5% 2.3% 2.1% 2.0% 1.9%
Paent Self-Harm 163 189 176 166 171 2.1% 2.3% 2.0% 2.0% 1.9%
Equipment/Supplies/
Devices
65 56 78 77 96 0.8% 0.7% 0.9% 0.9% 1.1%
Transfusion 18 17 52 58 33 0.2% 0.2% 0.6% 0.7% 0.4%
Total 7,886 8,094 8,595 8,364 9,042 100% 100% 100% 100% 100%
Note: Numbers shown for prior years may dier from previously published numbers due to subsequent report deleons or event type changes made by reporng
facilies.
24 I PatientSafetyJ.com I Vol. 4 No. 2 I June 2022
Paent Safety I Vol. 4 No. 2 I June 2022 I 25
2020 2021 Change in Reports 2020–2021
Event Type Event Subtype
Number
of
Reports
% of
Total
Reports
Number
of Serious
Events
% of
Total
Serious
Events
Number
of
Reports
% of
Total
Reports
Number
of Serious
Events
% of
Total
Serious
Events Number Percent
Error
Related
to P/T/T
Laboratory test problem 42,583 15.3% 49 0.6% 41,948 14.5% 28 0.3% -635 -1.5%
Surgery/invasive procedure problem 17,052 6.1% 517 6.2% 19,087 6.6% 516 5.7% 2,035 11.9%
Radiology/imaging test problem 7,439 2.7% 54 0.6% 8,158 2.8% 37 0.4% 719 9.7%
Referral/consult problem 7,286 2.6% 20 0.2% 7,838 2.7% 17 0.2% 552 7.6%
Other (specify) 9,653 3.5% 56 0.7% 7,826 2.7% 57 0.6% -1,827 -18.9%
Respiratory care 3,451 1.2% 49 0.6% 3,419 1.2% 66 0.7% -32 -0.9%
Dietary 1,871 0.7% 8 0.1% 2,176 0.8% 9 0.1% 305 16.3%
Medicaon
Error
Wrong 23,895 8.6% 85 1.0% 23,667 8.2% 71 0.8% -228 -1.0%
Other (specify) 10,337 3.7% 24 0.3% 12,244 4.2% 33 0.4% 1,907 18.4%
Dose omission 4,526 1.6% 18 0.2% 4,394 1.5% 20 0.2% -132 -2.9%
Prescripon/rell delayed 2,596 0.9% 6 0.1% 2,951 1.0% 3 0.0% 355 13.7%
Monitoring error (includes contraindicated drugs) 1,982 0.7% 9 0.1% 2,108 0.7% 15 0.2% 126 6.4%
Extra dose 1,504 0.5% 18 0.2% 1,804 0.6% 21 0.2% 300 19.9%
Medicaon list incorrect 946 0.3% 6 0.1% 743 0.3% 9 0.1% -203 -21.5%
Unauthorized drug 704 0.3% - - 737 0.3% - - 33 4.7%
Inadequate pain management 69 0.0% - - 67 0.0% - - -2 -2.9%
Complica-
on
of P/T/T
IV site complicaon (phlebis, bruising, inltraon) 11,688 4.2% 357 4.3% 11,896 4.1% 295 3.3% 208 1.8%
Other (specify) 6,583 2.4% 390 4.7% 7,312 2.5% 368 4.1% 729 11.1%
Complicaon following surgery or invasive procedure 6,756 2.4% 2,413 28.8% 6,414 2.2% 2,654 29.4% -342 -5.1%
Cardiopulmonary arrest outside of ICU seng 3,635 1.3% 78 0.9% 3,633 1.3% 84 0.9% -2 -0.1%
Catheter or tube problem 3,116 1.1% 235 2.8% 3,206 1.1% 208 2.3% 90 2.9%
Neonatal complicaon 2,456 0.9% 120 1.4% 2,591 0.9% 142 1.6% 135 5.5%
Maternal complicaon 2,351 0.8% 201 2.4% 2,527 0.9% 272 3.0% 176 7.5%
Extravasaon of drug or radiologic contrast 2,123 0.8% 28 0.3% 2,323 0.8% 27 0.3% 200 9.4%
Healthcare-associated infecon 1,968 0.7% 427 5.1% 1,184 0.4% 557 6.2% -784 -39.8%
Anesthesia event 1,207 0.4% 234 2.8% 1,142 0.4% 210 2.3% -65 -5.4%
Emergency department 1,263 0.5% 86 1.0% 983 0.3% 80 0.9% -280 -22.2%
Onset of hypoglycemia during care 2,031 0.7% 7 0.1% 918 0.3% 8 0.1% -1,113 -54.8%
Complicaon following spinal manipulave therapy 3 0.0% 1 0.0% 3 0.0% - - 0 0.0%
Fall
Found on oor 7,405 2.7% 262 3.1% 8,730 3.0% 328 3.6% 1,325 17.9%
Ambulang 5,114 1.8% 202 2.4% 5,098 1.8% 229 2.5% -16 -0.3%
Other/unknown (specify) 5,166 1.9% 96 1.1% 5,000 1.7% 92 1.0% -166 -3.2%
Toileng 3,408 1.2% 122 1.5% 3,573 1.2% 149 1.6% 165 4.8%
Lying in bed 2,564 0.9% 69 0.8% 3,258 1.1% 41 0.5% 694 27.1%
Sing in chair/wheelchair 2,817 1.0% 50 0.6% 3,101 1.1% 72 0.8% 284 10.1%
Assisted fall 2,748 1.0% 22 0.3% 2,923 1.0% 21 0.2% 175 6.4%
Table 6. Number and Percentage of Total Reports and Serious Events Submied to PA-PSRS by Event Type and Subtype in Descending Order by 2021 Frequency
26 I PatientSafetyJ.com I Vol. 4 No. 2 I June 2022
Table 6 (connued).
2020 2021 Change in Reports 2020–2021
Event Type Event Subtype
Number
of
Reports
% of
Total
Reports
Number
of Serious
Events
% of
Total
Serious
Events
Number
of
Reports
% of
Total
Reports
Number
of Serious
Events
% of
Total
Serious
Events Number Percent
Fall
(cont.)
Sing at side of bed 1,069 0.4% 21 0.3% 1,230 0.4% 24 0.3% 161 15.1%
Transferring 1,056 0.4% 26 0.3% 1,038 0.4% 33 0.4% -18 -1.7%
Hallways of facility 499 0.2% 19 0.2% 584 0.2% 11 0.1% 85 17.0%
From stretcher 306 0.1% 20 0.2% 378 0.1% 22 0.2% 72 23.5%
In exam room/from exam table 345 0.1% 14 0.2% 356 0.1% 11 0.1% 11 3.2%
Grounds of facility 278 0.1% 17 0.2% 333 0.1% 12 0.1% 55 19.8%
Other/
Miscella-
neous
Other (specify) 14,368 5.2% 331 4.0% 18,231 6.3% 381 4.2% 3,863 26.9%
Unancipated transfer to higher level of care 7,702 2.8% 314 3.8% 8,205 2.8% 400 4.4% 503 6.5%
Inappropriate discharge 1,019 0.4% 12 0.1% 1,140 0.4% 11 0.1% 121 11.9%
Other unexpected death 98 0.0% 49 0.6% 125 0.0% 51 0.6% 27 27.6%
Death or injury involving restraints - - - - 3 0.0% 3 0.0% 3 N/A
Death or injury during inpaent elopement 1 0.0% 1 0.0% 2 0.0% 2 0.0% 1 100%
Electric shock to paent 1 0.0% - - 1 0.0% - - 0 0.0%
Death or injury involving seclusion 1 0.0% 1 0.0% - - - - -1 -100.0%
Skin
Integrity
Pressure injury 7,467 2.7% 447 5.3% 8,085 2.8% 485 0 618 8.3%
Other (specify) 5,857 2.1% 38 0.5% 6,975 2.4% 40 0 1,118 19.1%
Skin tear 4,036 1.4% 17 0.2% 3,507 1.2% 15 0 -529 -13.1%
Abrasion 987 0.4% 5 0.1% 851 0.3% 3 0 -136 -13.8%
Blister 620 0.2% 4 0.0% 532 0.2% 5 0 -88 -14.2%
Laceraon 330 0.1% 35 0.4% 292 0.1% 33 0 -38 -11.5%
Burn (electrical, chemical, thermal) 201 0.1% 27 0.3% 203 0.1% 27 0 2 1.0%
Rash/hives 189 0.1% 2 0.0% 145 0.1% 4 0 -44 -23.3%
Venous stasis ulcer 10 0.0% - - 11 0.0% - - 1 10.0%
Equipment/
Supplies/
Devices
Equipment malfuncon 2,518 0.9% 22 0.3% 2,519 0.9% 29 0.3% 1 0.0%
Equipment not available 964 0.3% 2 0.0% 952 0.3% 4 0.0% -12 -1.2%
Other (specify) 878 0.3% 15 0.2% 942 0.3% 12 0.1% 64 7.3%
Medical device problem 932 0.3% 12 0.1% 724 0.3% 24 0.3% -208 -22.3%
Sterilizaon problem 669 0.2% 3 0.0% 696 0.2% 4 0.0% 27 4.0%
Broken item(s) 675 0.2% 14 0.2% 627 0.2% 14 0.2% -48 -7.1%
Equipment misuse 289 0.1% - - 281 0.1% 2 0.0% -8 -2.8%
Equipment safety situaon 281 0.1% 2 0.0% 230 0.1% 1 0.0% -51 -18.1%
Equipment wrong or inadequate 203 0.1% 2 0.0% 196 0.1% - - -7 -3.4%
Disconnected 244 0.1% 4 0.0% 190 0.1% 4 0.0% -54 -22.1%
Inadequate supplies 171 0.1% 1 0.0% 189 0.1% 2 0.0% 18 10.5%
Electrical problem 174 0.1% - - 165 0.1% - - -9 -5.2%
Outdated item(s) 64 0.0% - - 95 0.0% - - 31 48.4%
Paent Safety I Vol. 4 No. 2 I June 2022 I 27
Table 6 (connued).
2020 2021 Change in Reports 2020–2021
Event Type Event Subtype
Number
of
Reports
% of
Total
Reports
Number
of Serious
Events
% of
Total
Serious
Events
Number
of
Reports
% of
Total
Reports
Number
of Serious
Events
% of
Total
Serious
Events Number Percent
Adverse
Drug
Reacon
Other (specify) 3,543 1.3% 198 2.4% 3,939 1.4% 216 2.4% 396 11.2%
Skin reacon (rash, blistering, itching, hives) 1,407 0.5% 86 1.0% 1,289 0.4% 121 1.3% -118 -8.4%
Mental status change 210 0.1% 27 0.3% 160 0.1% 34 0.4% -50 -23.8%
Hematologic problem 137 0.0% 7 0.1% 130 0.0% 12 0.1% -7 -5.1%
Hypotension 123 0.0% 13 0.2% 127 0.0% 30 0.3% 4 3.3%
Nephrotoxicity 106 0.0% 8 0.1% 125 0.0% 12 0.1% 19 17.9%
Dizziness 57 0.0% 1 0.0% 67 0.0% 3 0.0% 10 17.5%
Arrhythmia 41 0.0% 4 0.0% 31 0.0% 2 0.0% -10 -24.4%
Transfusion
Other (specify) 1,705 0.6% 3 0.0% 1,674 0.6% 3 0.0% -31 -1.8%
Event related to blood product sample collecon 1,592 0.6% - - 1,470 0.5% - - -122 -7.7%
Event related to blood product administraon 915 0.3% 11 0.1% 912 0.3% 5 0.1% -3 -0.3%
Apparent transfusion reacon 832 0.3% 42 0.5% 783 0.3% 24 0.3% -49 -5.9%
Event related to blood product dispensing or distribuon 393 0.1% - - 428 0.1% - - 35 8.9%
Consent missing/inadequate 201 0.1% - - 259 0.1% - - 58 28.9%
Wrong paent requested 46 0.0% - - 48 0.0% - - 2 4.3%
Special product need not requested 16 0.0% - - 17 0.0% 1 0.0% 1 6.3%
Wrong component issued 27 0.0% 2 0.0% 17 0.0% - - -10 -37.0%
Special product need not issued 25 0.0% - - 16 0.0% - - -9 -36.0%
Mismatched unit 13 0.0% - - 11 0.0% - - -2 -15.4%
Wrong component requested 11 0.0% - - 8 0.0% - - -3 -27.3%
Wrong paent transfused 3 0.0% - - 5 0.0% - - 2 66.7%
Paent
Self-Harm
Other self-harm (specify) 1,231 0.4% 68 0.8% 1,271 0.4% 61 0.7% 40 3.2%
Self-mulaon 881 0.3% 27 0.3% 827 0.3% 19 0.2% -54 -6.1%
Ingeson of foreign object or substance 189 0.1% 44 0.5% 229 0.1% 70 0.8% 40 21.2%
Suicide aempt – injury 15 0.0% 15 0.2% 17 0.0% 17 0.2% 2 13.3%
Suicide – death 12 0.0% 12 0.1% 4 0.0% 4 0.0% -8 -66.7%
Anorexia/bulimia 1 0.0% - - 3 0.0% - - 2 200.0%
Total 278,530 100% 8,364 100% 288,882 100% 9,042 100% 10,352
28 I PatientSafetyJ.com I Vol. 4 No. 2 I June 2022
Table 7. Top 20 Words With Respect to Increase in Associated
PA-PSRS Reports Submied as Other/Miscellaneous, Other
(Specify)
Top 20 Words
Number of
Reports
Containing the
Word in 2020
Number of
Reports
Containing the
Word in 2021
Increase in
Number of
Reports from
2020 to 2021
response 1,063 2,083 1,020
delay 1,323 2,161 838
condion 832 1,474 642
transfer 647 1,269 622
lack 761 1,362 601
care 326 871 545
rapid 232 682 450
failure 1,364 1,771 407
without 208 601 393
procedure 822 1,207 385
higher 82 456 374
level 101 452 351
follow 877 1,197 320
policy 966 1,239 273
followed 528 765 237
cancelled 348 551 203
safety 571 762 191
act 185 317 132
due 197 329 132
family 224 351 127
Table 8. Number of Reports Submied to PA-PSRS in 2021 by Event Type and Harm Score in Descending Order by Event
Type Frequency
Event Type
A B1 B2 C D E F G H I
Total
Error Related to P/T/T 14,367 1,127 10,843 44,141 19,244 514 160 14 22 20 90,452
Medicaon Error 3,028 770 19,757 17,275 7,713 131 30 1 6 4 48,715
Complicaon of P/T/T 2,134 106 837 12,389 23,761 3,123 1,535 38 76 133 44,132
Fall 192 57 248 18,931 15,129 821 207 2 8 7 35,602
Other/Miscellaneous 4,989 527 2,157 8,543 10,643 535 233 5 18 57 27,707
Skin Integrity 614 14 59 4,912 14,390 591 16 3 2 0 20,601
Equipment/Supplies/
Devices
1,320 111 1,291 3,412 1,576 70 14 3 4 5 7,806
Adverse Drug Reacon 79 7 20 1,070 4,262 374 50 0 4 2 5,868
Transfusion 1,245 47 622 2,267 1,434 25 7 0 0 1 5,648
Paent Self-Harm 35 6 40 745 1,354 146 18 0 3 4 2,351
Total 28,003 2,772 35,874 113,685 99,506 6,330 2,270 66 143 233 288,882
Cross Tabulaons
Event Type and Harm Score
Table 8 displays a cross tabulation of submitted reports dis-
tributed by harm score for each of the 10 event types. Colored
cells reect the intersections of event type and harm score
that occurred most frequently in 2021, with darker shades
representing a higher concentration of reports. For the most
frequently reported event type, Error Related to P/T/T, harm
score C was reported most frequently; this intersection of event
type and harm score was the most common in 2021, with a
total of 44,141 reports and representing 15.2% of all reported
events. The second most common intersection is with event
type Complication of P/T/T and harm score D, with a total of
23,761 events and representing 8.2% of all reported events.
Care Area and Harm Score
The Care Area (i.e., location where an event occurred) can
help us determine whether there are patterns or trends in
reports of specic patient safety concerns related to the
location where care is delivered. Within the acute care data,
there are 168 care areas for facilities to identify where events
occur. We then place these care areas into one of 23 care
area groups to cross tabulate a more manageable number
of category elements with other variables of interest.
In Table 9 we show a cross tabulation of care area group with
harm score. The highest concentrations of reports appear
in the cross sections of the Med/Surg care area group and
harm scores C and D. Also, Surgical Services accounts for a
large portion of harm scores E and F.
Table 10 shows a cross tabulation of care area group and
event type. The two highest concentrations of reports are
at the intersections of Error Related to P/T/T with Surgical
Services (18,340) and Emergency (14,314) care area groups.
The third highest concentration is seen at the intersection
of Fall and Med/Surg (13,301).
Harm Score
Paent Safety I Vol. 4 No. 2 I June 2022 I 29
Table 9. Number of Reports Submied to PA-PSRS in 2021 by Care Area Group and Harm Score in Descending Order by
Care Area Group Frequency
Care Area Group A B1 B2 C D E F G H I Total
Med/Surg 5,050 399 3,635 23,476 23,575 952 249 7 16 50 57,409
Surgical Services 4,634 539 4,679 13,422 11,331 2,431 1,381 31 64 51 38,563
Emergency 5,658 274 2,464 12,893 7,104 312 75 3 8 26 28,817
ICU 2,367 142 1,696 8,980 10,722 517 61 4 18 33 24,540
Specialty Unit 1,579 159 1,114 8,060 7,209 298 67 1 11 15 18,513
Imaging/Diagnosc 1,049 150 1,235 6,008 6,983 219 89 6 5 12 15,756
Pediatric 1,014 73 4,983 3,732 1,602 57 17 1 0 5 11,484
Other 1,184 202 1,883 4,150 3,438 195 115 1 3 6 11,177
Laboratory 768 226 1,616 5,830 2,454 22 8 1 0 0 10,925
PICU 766 24 5,794 3,075 740 34 2 0 1 1 10,437
Psychiatric Unit 313 63 311 3,817 4,301 376 31 0 2 8 9,222
Clinic/Outpaent Oce 545 86 1,426 3,602 3,136 184 45 2 1 3 9,030
Rehab Unit 344 67 353 3,914 4,142 140 27 2 4 2 8,995
Intermediate Unit 693 100 469 3,318 3,956 101 25 1 2 5 8,670
NICU 483 31 1,803 3,337 1,290 39 3 0 2 2 6,990
Labor and Delivery 338 32 215 1,403 3,597 203 29 4 6 6 5,833
OB/GYN Unit 457 61 410 1,602 1,903 196 32 2 0 3 4,666
Pharmacy 331 103 1,355 1,257 567 7 2 0 0 0 3,622
Rehab Services 135 12 94 1,087 579 21 6 0 0 3 1,937
Nursery 96 6 67 364 698 20 4 0 0 2 1,257
Administraon 98 13 230 118 95 4 2 0 0 0 560
Respiratory 101 10 42 240 84 2 0 0 0 0 479
Total 28,003 2,772 35,874 113,685 99,506 6,330 2,270 66 143 233 288,882
Harm Score
Table 10. Number of Reports Submied to PA-PSRS in 2021 by Care Area Group and Event Type in Descending Order by
Care Area Group Frequency
Care Area Group
Error Related
to P/T/T
Medicaon
Error
Complication
of P/T/T
Fall
Other/
Miscellaneous
Skin
Integrity
Equipment/
Supplies/
Devices
Adverse Drug
Reacon
Transfusion
Paent
Self-Harm
Total
Med/Surg 10,474 10,119 7,775 13,301 6,965 5,911 716 897 1,156 95 57,409
Surgical Services 18,340 1,720 8,451 594 3,585 1,773 3,265 288 539 8 38,563
Emergency 14,314 3,373 2,633 3,294 3,040 234 394 486 903 146 28,817
ICU 6,880 4,330 3,028 1,252 1,579 5,676 623 325 824 23 24,540
Specialty Unit 3,367 3,506 2,434 3,713 2,487 1,767 218 410 582 29 18,513
Imaging/Diagnosc 6,542 215 5,328 816 862 494 438 1,034 22 5 15,756
Pediatric 1,871 5,783 1,690 509 885 197 357 19 138 35 11,484
Other 3,845 1,844 1,315 1,289 1,409 488 301 467 211 8 11,177
Laboratory 9,970 34 108 98 221 18 38 5 433 0 10,925
PICU 2,254 6,151 1,086 44 251 196 349 6 98 2 10,437
Psychiatric Unit 375 879 170 3,959 1,569 220 22 62 0 1,966 9,222
Clinic/Outpaent 3,227 1,279 992 745 676 198 228 1,475 201 9 9,030
Rehab Unit 834 1,268 717 3,346 946 1,704 67 84 25 4 8,995
Intermediate Unit 1,714 1,233 1,330 1,363 1,410 1,165 143 105 193 14 8,670
NICU 2,728 2,233 927 4 503 166 330 2 97 0 6,990
Labor and Delivery 1,302 323 3,439 139 330 55 95 26 123 1 5,833
OB/GYN Unit 1,387 627 1,793 174 433 63 85 22 79 3 4,666
Pharmacy 59 3,375 10 1 37 0 6 134 0 0 3,622
Rehab Services 146 67 202 919 317 243 33 3 6 1 1,937
Nursery 435 63 638 8 65 13 30 1 4 0 1,257
Administraon 162 226 31 20 63 6 22 15 14 1 560
Respiratory 226 67 35 14 74 14 46 2 0 1 479
Total 90,452 48,715 44,132 35,602 27,707 20,601 7,806 5,868 5,648 2,351 288,882
Event Type
Other Acute Care Facilies
Considering that the acute care data predominately reflects
reports from hospitals, it is important to separately analyze data
from the other acute care facilities that report to PA-PSRS (com-
prised mostly of ASFs, along with BRCs and ABFs). Table 11 shows
the distribution of reports submitted by other acute care facilities
across the 10 event types. These facilities show a dierent dis-
tribution compared to the overall data in Table 4. In 2021, other
acute care facilities reported medication error and fall events less
frequently than other event types when compared to the overall
data (see Tables 4 and 11). The three event types reported most
frequently by other acute care facilities were Error Related to
P/T/T, Complication of P/T/T, and Other/Miscellaneous, which
together account for 90.6% of all reports submitted by other acute
care facilities in 2021.
For other acute care facilities, the Complication of P/T/T event
type accounted for 71.0% of all serious events submitted in 2021
(see Table 12).
COVID-19
Eect on the Number of Event Occurrences
For purposes of this section, data were analyzed based on the date
on which the event occurred (“event occurrence”). Figure 4 shows
the number of event occurrences during the COVID-19 pandemic
in 2020 and 2021.
Eect on the Rate of Falls
The COVID pandemic has created challenging conditions that
impact healthcare providers’ ability to respond to patient needs
in a timely manner.
2
Figure 5 shows the rates for falls through
Q2 2021—the latest calendar quarter for which we have patient
day and surgery count data. Figure 6 reflects the number of
falls based on event occurrence date by month. Based on data
from PA-PSRS reports, the largest number of falls occurred in
December 2020.
Paent Safety I Vol. 4 No. 2 I June 2022 I 31
Table 12. Number and Percentage of Serious Events Submied to PA-PSRS by Other Acute Care Facilies (ASF, BRC, ABF)
by Event Type in Descending Order by 2021 Frequency
Number of ReportsNumber of Reports % of Total Reports% of Total Reports
Event TypeEvent Type 2017 2017 2018 2018 2019 2019 2020 2020 2021 2021 2017 2017 2018 2018 2019 2019 2020 2020 2021 2021
Complicaon of P/T/TComplicaon of P/T/T 1,223 1,223 1,198 1,198 1,272 1,272 1,179 1,179 1,372 1,372 67.2%67.2% 68.2%68.2% 67.1%67.1% 72.0%72.0% 71.0%71.0%
Other/MiscellaneousOther/Miscellaneous 463 463 434 434 478 478 300 300 416 416 25.4%25.4% 24.7%24.7% 25.2%25.2% 18.3%18.3% 21.5%21.5%
Error Related to P/T/TError Related to P/T/T 65 65 54 54 57 57 74 74 55 55 3.6%3.6% 3.1%3.1% 3.0%3.0% 4.5%4.5% 2.8%2.8%
FallFall 27 27 18 18 17 17 18 18 29 29 1.5%1.5% 1.0%1.0% 0.9%0.9% 1.1%1.1% 1.5%1.5%
Skin IntegritySkin Integrity 15 15 23 23 30 30 23 23 21 21 0.8%0.8% 1.3%1.3% 1.6%1.6% 1.4%1.4% 1.1%1.1%
Adverse Drug ReaconAdverse Drug Reacon 12 12 17 17 17 17 24 24 17 17 0.7%0.7% 1.0%1.0% 0.9%0.9% 1.5%1.5% 0.9%0.9%
Equipment/Supplies/Equipment/Supplies/
DevicesDevices
6 6 5 5 10 10 10 10 13 13 0.3%0.3% 0.3%0.3% 0.5%0.5% 0.6%0.6% 0.7%0.7%
Medicaon ErrorMedicaon Error 8 8 5 5 14 14 5 5 8 8 0.4%0.4% 0.3%0.3% 0.7%0.7% 0.3%0.3% 0.4%0.4%
TransfusionTransfusion - - 1 1 1 1 - - 1 1 0.0%0.0% 0.1%0.1% 0.1%0.1% 0.0%0.0% 0.1%0.1%
Paent Self-HarmPaent Self-Harm 1 1 1 1 1 1 5 5 1 1 0.1%0.1% 0.1%0.1% 0.1%0.1% 0.3%0.3% 0.1%0.1%
TotalTotal 1,820 1,820 1,756 1,756 1,897 1,897 1,638 1,638 1,933 1,933 100%100% 100%100% 100%100% 100%100% 100%100%
Note: Numbers shown for prior years may dier from previously published numbers due to subsequent report deleons or event type changes made by reporng
facilies.
Table 11. Number and Percentage of Reports Submied to PA-PSRS by Other Acute Care Facilies (ASF, BRC, ABF) by
Event Type in Descending Order by 2021 Frequency
Number of Reports % of Total Reports
Event Type 2017 2018 2019 2020 2021 2017 2018 2019 2020 2021
Error Related to P/T/T 2,804 3,092 3,538 3,048 3,333 32.8% 35.5% 38.2% 39.0% 35.8%
Complicaon of P/T/T 2,420 2,426 2,478 2,265 2,816 28.3% 27.9% 26.7% 29.0% 30.3%
Other/Miscellaneous 2,543 2,504 2,417 1,766 2,283 29.7% 28.8% 26.1% 22.6% 24.5%
Skin Integrity 233 209 246 206 245 2.7% 2.4% 2.7% 2.6% 2.6%
Fall 156 141 150 161 222 1.8% 1.6% 1.6% 2.1% 2.4%
Equipment/Supplies/
Devices
162 133 180 145 160 1.9% 1.5% 1.9% 1.9% 1.7%
Medicaon Error 163 104 173 129 137 1.9% 1.2% 1.9% 1.7% 1.5%
Adverse Drug Reacon 63 84 79 77 100 0.7% 1.0% 0.9% 1.0% 1.1%
Paent Self-Harm 4 6 2 10 5 0.0% 0.1% 0.0% 0.1% 0.1%
Transfusion - 3 1 - 3 0.0% 0.0% 0.0% 0.0% 0.0%
Total 8,548 8,702 9,264 7,807 9,304 100% 100% 100% 100% 100%
Note: Numbers shown for prior years may dier from previously published numbers due to subsequent report deleons or event type changes made by reporng
facilies.
32 I PatientSafetyJ.com I Vol. 4 No. 2 I June 2022
30,000
25,000
20,000
15,000
10,000
5,000
0
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D
Figure 4. PA-PSRS Reports From Hospitals and Other Acute Care Facilies Based on Event Occurrence Date by Month
Number of
Hospital Reports
Number of Other Acute
Care Facility Reports
3,000
2,500
2,000
1,500
1,000
500
0
2019 2020 2021
Figure 5. Rates of Falls at Hospitals and ASFs Based on Fall Occurrence Date in PA-PSRS per 1,000 Paent Days (Hospitals)
or 1,000 Surgical Encounters (ASFs)
3.67
3.98
3.76
4.01
3.86
3.71
3.77
3.66
3.58
0.17
0.27
0.20
0.15
0.24
0.15
0.17
0.13
0.14
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
0.17
3.80
2019 2020 2021
Hospitals
ASFs
Fall Rate
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D
3,500
3,000
2,500
2,000
1,500
1,000
500
0
Figure 6. PA-PSRS Fall Reports Based on Event Occurrence Date by Month
Number of Reports
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D
2019 2020 2021
Conclusion
There were 288,882 acute care events reported in PA-PSRS during
2021, representing a 3.7% increase from 2020. The number of
reported high harm events has decreased from 726 in 2005 to 442
in 2021. The 442 high harm events submitted in 2021 was a 6.0%
increase over the 417 submitted in 2020; however, the proportion
of high harm events remained steady at 0.15%, and very close to
the average of 0.16% over the past 10 years.
The top four event types, accounting for more than three-
quarters of the acute event reports in 2021, were Error Related
to P/T/T, Medication Error, Complication of P/T/T, and Fall. The
Other (specify) event subtype within the Other/Miscellaneous
event type had the largest increase in representative percentage
of all reports from 2020 to 2021, increasing from 5.2% to 6.3%
of all reports.
Based on our analysis of PA-PSRS reports, the COVID-19 pandemic
appears to have had an impact on patient safety in 2021, with
hospital fall rates increasing during pandemic peaks in Q2 2020
and Q4 2020, followed by declines in Q1 and Q2 2021.
Note
This analysis was exempted from review by the Advarra
Institutional Review Board.
References
1. Pennsylvania Department of Health. Medical Care
Availability and Reduction of Error (MCARE) Act, Pub. L. No.
154 Stat. 13 (2002). DOH website. https://www.health.pa.gov/
topics/Documents/Laws%20and%20Regulations/Act%2013%20
of%202002.pdf. Published 2002. Accessed April 12, 2022.
2. Taylor M, Kepner S, Gardner L, Jones R. Patient Safety
Concerns in COVID-19–Related Events: A Study of 343 Event
Reports From 71 Hospitals in Pennsylvania. Patient Saf. 16-27.
10.33940/data/2020.6.3.
About the Authors
Shawn Kepner (shawkepner@pa.gov) is a statistician at the Patient
Safety Authority.
Rebecca Jones is director of Data Science and Research at the
Patient Safety Authority (PSA) and founder and director of the
PSA’s Center of Excellence for Improving Diagnosis.
Paent Safety I Vol. 4 No. 2 I June 2022 I 33
This arcle is published under the Creave Commons Aribuon-
NonCommercial license.