COVID-19 (i.e., coronavirus disease 2019) was declared a pandemic and has had a profound impact on healthcare systems, which may increase the risk of patient harm. We conducted a query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to identify COVID-19–related events submitted by acute care hospitals between January 1 and April 15, 2020. We identified 343 relevant event reports from 71 hospitals and conducted a descriptive study to identify the prevalence of and relationships between 13 categories of associated factors and 6 categories of event outcomes. We found that 36% (124 of 343) of events had more than one associated factor and 24% (83 of 343) had more than one outcome. The most frequently identified factors were Laboratory Testing (47%; 161 of 343), Process/Protocol (25%; 87 of 343), and Isolation Integrity (22%; 74 of 343). The two most frequent outcomes were Exposure to COVID-19 Positive or Suspected Positive Patient (50%; 173 of 343) and Missed/Delayed Test or Result (31%; 108 of 343). Finally, the findings showed that seven of the associated factors had a notable impact on the frequency of Exposure to COVID-19 Positive or Suspected Positive Patient outcome. Overall, we anticipate that the results can be used to identify areas of greatest need and risk, which could help to guide allocation of resources to mitigate risk of patient harm.

Policy maker efforts to evaluate the quality and costs of health care have stimulated a proliferation of disparate performance measures. This cacophony of performance measures creates confusion over which measures are applicable at which level of the health care system, limiting their effective application for accountability and improvements in patient care. The American College of Physicians (ACP) has created a clinical performance measurement framework to provide direction to policy makers and measure developers for future performance measure development and application. The ACP believes that this clinical performance measurement framework is one way to help promote transformational change in patient care through judicious application of performance measures. Recommendation. The ACP recommends that policy makers and measure developers adopt this clinical performance measurement framework to promote transformational change and improve the quality of health care in the United States.

The PA-PSRS falls reporting program's standardized definition of falls offers new analytic reports that include falls rates with benchmarking data and a falls dashboard. The benchmarking data allow hospitals to compare themselves to peer hospitals statewide. The newly expanded PA-PSRS falls reporting program has turned an adverse event-reporting program into a quality improvement tool.

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.