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As the journal of the Patient Safety Authority, committed to the vision of “safe healthcare for all patients," Patient Safety (ISSN 2689-0143) is fully open access and highlights original research, advanced analytics, and hot topics in healthcare. The mission of this publication is to inform and advise clinicians, administrators, and patients on preventing harm and improving safety, by providing evidence-based, original research; editorials addressing current and sometimes controversial topics; and analyses from one of the world’s largest adverse event reporting databases. We invite you to submit manuscripts that align with our mission. We’re particularly looking for well-written original research articles, reviews, commentaries, case studies, data analyses, quality improvement studies, or other manuscripts that will advance patient safety. All articles are published under the Creative Commons Attribution – Noncommercial license, unless otherwise noted. The current issue is available at patientsafetyj.com. The patient is central to everything we do. Patient Safety complies with the Patients Included™ journal charter, which requires at least two patient members on the editorial board; regular publication of editorials, reviews, or research articles authored by patients; and peer review by patients. This publication is disseminated quarterly by email at no cost to the subscriber. To subscribe, go to patientsafetyj.com. Articles accepted for publication do not necessarily reflect practices or opinions endorsed by the Patient Safety Authority.

First, I would like to wish all our readers, authors, reviewers, and staff a happy holiday season! Here at Patient Safety, we have many reasons to celebrate. Did you know that Patient Safety articles have been viewed and or downloaded over 285,000 times since we launched in September 2019? Or that we are read in 175 countries?! While being read around the world is in itself an amazing accomplishment, knowing that our collective work and passion for patient safety is impacting real lives around the world leaves me without words. In the following pages, don’t miss a safety alert issued by the Patient Safety Authority and ECRI. This short but critical piece describes an event where a patient experienced an air embolism (life-threatening emergency) during a cardiac ablation procedure. Michelle Bell and Bruce Hansel describe the issue and steps healthcare providers can take to mitigate this risk. Poor communication is a well-recognized cause for many disconnects in healthcare, and because it is so well recognized, many hospitals have programs for improvement—though most don’t focus on the continuum from one point of care to the next. Abigail Baluyot et al. looked beyond their institution and identified vulnerabilities within hospital and skilled nursing facility hand-offs. The team implemented an improvement program that resulted in significantly reduced wait times for important treatments, such as intravenous medications, in the post-acute setting. You may remember the article on perioperative delirium and agitation published in our December 2021 issue that brought to light the patient and staff safety issues surrounding delirium in the perioperative setting. In a follow-up manuscript, Taylor et al. outline a patient safety initiative that one Veterans Affairs hospital implemented to minimize its occurrence. Their manuscript invites the opportunity for further study on this important safety topic. Our future depends on the next generation of healthcare providers. This issue includes a small but crucial study by Toothaker et al. that describes the transition of our next generations of nurses into the workforce and the safety challenges they face, and an interview by managing editor, Caitlyn Allen, with longtime nursing professor Eileen Fruchtl, who discusses what the future of nursing education may hold. Other features in this issue include an update to acute care reporting rates in Pennsylvania by data editor and data scientist Shawn Kepner; a discussion with Erica Benning, Bureau of Healthcare director, Pennsylvania Department of Corrections, for an inside look of healthcare in the prison system; and an interview with John Olsen, et al. that tells us how a team from Jefferson Health implemented RISE: a formal peer support program that has only become more valuable following the pandemic. This journal was designed for our authors to freely share the important work they do to improve patient safety, and for our readers to freely receive the information, strategies, and lessons learned to make the care they provide and receive safer. Thank you to our authors, reviewers, staff, editorial board, and readers for your continued contributions. Stay safe and stay well!

As the journal of the Patient Safety Authority, committed to the vision of “safe healthcare for all patients," Patient Safety (ISSN 2689-0143) is fully open access and highlights original research, advanced analytics, and hot topics in healthcare. The mission of this publication is to inform and advise clinicians, administrators, and patients on preventing harm and improving safety, by providing evidence-based, original research; editorials addressing current and sometimes controversial topics; and analyses from one of the world’s largest adverse event reporting databases. We invite you to submit manuscripts that align with our mission. We’re particularly looking for well-written original research articles, reviews, commentaries, case studies, data analyses, quality improvement studies, or other manuscripts that will advance patient safety. All articles are published under the Creative Commons Attribution – Noncommercial license, unless otherwise noted. The current issue is available at patientsafetyj.com. The patient is central to everything we do. Patient Safety complies with the Patients Included™ journal charter, which requires at least two patient members on the editorial board; regular publication of editorials, reviews, or research articles authored by patients; and peer review by patients. This publication is disseminated quarterly by email at no cost to the subscriber. To subscribe, go to patientsafetyj.com.

As our second pandemic winter approaches in North America, we are in a much different place than we were a year ago. According to the Centers for Disease Control and Prevention, more than 194 million people in the United States have been fully vaccinated against COVID-19. Last month, the Food and Drug Administration approved the first vaccines for children ages 5 to 12, a huge relief for many parents, including me. We now have real hope that we might soon see the end of this pandemic—but it isn’t over yet. Colder weather will bring more activities indoors, and the holiday season will bring families and friends together in celebration. Both increase the risk of spreading respiratory diseases. While the pandemic continues, we are only just beginning to understand its long-term impact on healthcare. Nurses have been carrying a heavy burden: caring for COVID-19 patients on the front lines, risking their own safety as well as the safety of their loved ones. Just when we need them most, many nurses feel abandoned and expendable. In one of our cover stores, Cassandra Alexander relates the toll the daily struggle has taken on her mental health—a sobering glimpse at the experiences of nurses like her around the country. When it comes to both the pandemic and patient safety, we know two things: positive change takes time, and we are all in it together. One critical way to make healthcare safer is to involve the patients themselves. Managing Editor Cait Allen interviewed patient engagement expert Dr. Judith Hibbard about why it is important to activate patients in their own healthcare and how to do it. And to demonstrate the benefits of patients being informed and engaged, Rick Kundravi shares how his mother’s lifestyle helped her avoid many of the health problems associated with aging. We also know that when clinicians work closely with their patients, there are usually better outcomes, in some cases for both the patients and healthcare staff. This is a strategy for mitigating the risk of perioperative delirium and agitation, one of several interventions that researchers Matthew Taylor and William Pileggi offer in their data analysis of safety events related to the use of anesthetics. Also featured this month: Lea Anne Gardner and Melanie Motts look at the challenges new-onset atrial fibrillation presents for ambulatory surgical facilities, with an analysis of surveys and data related to cancellations and transfers. Guidelines discourage using benzodiazepines in conjunction with opioid pain medications in older adults—so why is it still happening, how often does it occur, and what are the consequences for geriatric patients? Elizabeth Kukielka addresses these questions and more in a new data analysis. Urinary tract infections (UTIs) are often treated in long-term care facilities, but they’re notoriously difficult to diagnose. To better understand the reasons and risks for residents, authors Amy Harper and Shawn Kepner studied the patient safety event reports and share the trends in rates and most common types of infections, as well as a toolkit they developed to help reduce the occurrence of UTIs and promote antibiotic stewardship. Best wishes for a safe, healthy holiday season!

Lisa Rodebaugh: My husband, Bill, and I can rattle off our stories in two minutes or less—stories from having five children, each with varying medical and developmental needs that presented far differently from what specialists typically see. Each required those who knew them best asking questions to get them the right help at the right time. We tell the stories often, to encourage those listening to always ask the questions. We tell the stories often, because self-advocacy matters. Sometimes it is the difference between life and death. My oldest son, now 21, was 6 months old and kept running a low-grade fever. I diligently called the pediatrician when it began and called again when it did not go away after 10 days. The doctor was convinced there was nothing to worry about: most likely he just had two different colds, and there was no way the fever would last long. Three weeks later and with my son still running a fever, I called again insisting we be seen. They agreed to see us—after giving me the “new mom chat,” an assurance that everything was probably fine and a request to not worry so much. Thankfully, they sent us for lab work, because by this point, my son was in septic shock. We spent the next few days in the hospital. He recovered, and I was equipped with information and the confidence to never stop asking questions. One year later, my second child was born with a condition called hypoplastic left heart syndrome (HLHS), a congenital condition (something you’re born with) that affects blood flow through the heart. His first of three open-heart surgeries happened when he was just 8 days old. Two months later, I noticed his chest looked buff, like a little Arnold Schwarzenegger. The cardiologist humored me with a visit, only because we were in the precarious time between our son’s surgeries. Again, I got that “do not worry so much” chat. Immediately following an echocardiogram, our infant son was rushed into the cardiac cath lab to unblock a critical opening between his heart chambers that had unexpectedly closed with scar tissue. Once again, the life of one of my children was saved by asking questions and being persistent. Those are the most dramatic stories. However, there are countless more in my two decades of parenting that have made me never regret following my gut—parental intuition is real and can be lifesaving. Advocating for my children forced me to step outside my comfort zone. Often, I had to question what someone with specific training in that specialty was telling me. Often, I had to keep pressing because I knew something was wrong. In the 20 years since To Err is Human was published, we have come a long way in having a patient’s or caregiver’s voice validated, but this is an area where we can continue to grow and evolve. I try not to think what would have happened had I shrunk in my corner as a new mom, not knowing how very critical my observations were. Trust your instincts. Ask questions.

Meet Queen Quet Marquetta L. Goodwine—computer scientist turned head-of-state. Since 2000, she has led the Gullah/Geechee Nation, a group of more than 1 million inhabitants on the southeastern shores of the United States. She sat down with Editor-in-Chief Regina Hoffman to discuss life on the Sea Islands, strategies to improve care for minority patients, and how one Gullah/Geechee native launched a national movement to defend workers’ rights—and why you have never heard about it.

As the journal of the Patient Safety Authority, committed to the vision of “safe healthcare for all patients,” Patient Safety (ISSN 2689-0143) is fully open access and highlights original research, advanced analytics, and hot topics in healthcare. The mission of this publication is to inform and advise clinicians, administrators, and patients on preventing harm and improving safety, by providing evidence-based, original research; editorials addressing current and sometimes controversial topics; and analyses from one of the world’s largest adverse event reporting databases. We invite you to submit manuscripts that align with our mission. We’re particularly looking for well-written original research articles, reviews, commentaries, case studies, data analyses, quality improvement studies, or other manuscripts that will advance patient safety. All articles are published under the Creative Commons Attribution – Noncommercial license, unless otherwise noted. The current issue is available at patientsafetyj.com. The patient is central to everything we do. Patient Safety complies with the Patients Included™ journal charter, which requires at least two patient members on the editorial board; regular publication of editorials, reviews, or research articles authored by patients; and peer review by patients. This publication is disseminated quarterly by email at no cost to the subscriber. To subscribe, go to patientsafetyj.com.

We enter the winter holiday season amidst the worst health crisis most of us have ever known. It is so difficult to think about anything other than masks and vaccines and how to eradicate an invisible enemy. In fact, it can be all-consuming. However, an additional challenge is how to keep our heads out of the sand in relation to all the other issues that affect patients and their loved ones daily. One of our goals at Patient Safety throughout this pandemic has been to continue to shine light on the ongoing patient safety crisis that plagues our healthcare system day in and day out. Wrong-site surgery (WSS) is one of those things that is never supposed to happen. I experienced a WSS myself, as a former patient safety officer who was working for the Patient Safety Authority (PSA) at the time. I assure you, if it can happen to me, it can happen to you. While this may be an old topic in patient safety, it is still very real and still happens—daily across the globe and 1.42 times weekly in Pennsylvania! Take a look at the various ways PSA staff Robert Yonash and Matthew Taylor broke down and analyzed this data to help give us the clearest picture of these events to date. Our collective challenge is how to make significant improvement in this area. The guidelines are out there. Why are we not following them? I had the privilege and honor of sitting down (virtually) with Queen Quet, chieftess and head-of-state for the Gullah/Geechee Nation, to discuss some of the unspoken challenges we face in healthcare. Patient safety isn’t always about what goes right or wrong in the healthcare setting. It is also about those patients who never reach our doors for various reasons. Patient safety and quality of care starts in our communities. I invite you to learn a little history about a nation within our nation and how we can start to meet the needs of all our communities right now. Adding to the dialogue about ongoing patient safety issues, Cait Allen, our managing editor, spoke with Dr. David F. Gaieski, director of Emergency Critical Care at Jefferson Health, to talk about sepsis, its interplay with COVID-19, and why it’s a big deal. Additional articles include a unique perspective related to health IT and wrong-patient errors; events related to prone positioning, a common body position for treating patients with acute respiratory distress syndrome; a patient perspective from someone who lived through childhood polio, underscoring the importance of vaccinations; and several others. Finally, we at Patient Safety and the PSA thank healthcare workers and all essential employees for your dedication and sacrifices through these most trying times. We wish you a very safe holiday season!

Pennsylvania is the only state that requires acute healthcare facilities to report all events of harm or potential for harm. With over 3.6 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. Of the 293,400 patient safety event reports submitted by Pennsylvania’s acute care facilities in 2019, 97% were from hospitals, and 3% were from ambulatory surgical facilities (ASFs). The vast majority of these reports were Incidents (284,847), rather than Serious Events (8,553). Reporting rates for both hospitals and ASFs increased 26% from 2015 to 2019, which is likely due to changes in reporting guidance in 2015. For each of the last five years, the most frequently reported event type was “Error Related to Procedure/Treatment/Test,” (EPTT), with this event type accounting for 33% of all submitted acute care event reports in 2019. “Medication Error,” “Complication of Procedure/Treatment/Test” and “Fall” events were also reported frequently, accounting for 18%, 16%, and 11% of all submitted event reports in 2019, respectively. The increase in reporting rates each year may reflect improvements in patient safety culture across the Commonwealth, and the analysis within this article highlights a number of areas in which continued patient safety efforts can be applied to reduce harm in acute care settings.

The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States. In addition to over 3.6 million Acute Care records, PA-PSRS has collected more than 330,000 Long-Term Care (LTC) healthcare-associated in­fection reports since 2009. A total of 28,310 infections were reported in 2019, representing a 9% decrease from the prior year. The Northwest region of the state had the highest infection reporting rate, with 1.25 reports per 1,000 resident days. There was a 20% reduction in both the number and reporting rate of respiratory tract infections from 2018 to 2019; however, respiratory tract infections remained the most frequently reported infection type overall. Cellulitis, soft tissue, or wound infection was the most frequently reported infection subtype in 2019, followed by pneumonia and symptomatic urinary tract infection. With this information, nursing homes and interested parties can determine which trends or characteristics of the data are relevant for reduction in infections in nursing homes. Overall, this analysis demonstrates areas in which continued education and infection prevention measures can be applied to further enhance the safety for residents in long-term care facilities.

Thank you to every reader, author, reviewer, editorial board member, and staff person for making the launch of Patient Safety a success. In a short period of time, nearly 7,000 people from over 120 countries and all 50 United States read the inaugural issue. I also extend a special thanks to our patient representatives, who dedicate their time and energy through this journal and many other initiatives to make care safer for others. Our December issue features a patient perspective piece by Kristin Aaron, who shares the tragic healthcare journey of her son, Jenson (featured on our cover), and how great change often starts with a single step. Our back inside cover features The Walking Gallery jacket #160 Cancer for Christmas. Casey Quinlan, diagnosed with breast cancer just days before Christmas in 2007, leveraged her experience to help others navigate cancer treatment. Quinlan was a charter author for Patients Included™, a nonprofit inspiring organizations to include patients in their work. I am proud to say Patient Safety is a Patients Included™ publication. Also from our cover: Cait Allen, director of engagement and managing editor with the Patient Safety Authority, sat down with Kathleen Noonan, chief executive officer of the Camden Coalition of Healthcare Providers, to talk about some innovative solutions to meet the needs of a very at-risk population. Elizabeth Kukielka and co-authors discuss the findings of a database analysis related to telemetry monitoring; this article was inspired by a deep dive into events in Pennsylvania that cause high harm and death to patients. And finally, Sara Kolc Brown and co-authors share one facility’s initiative to decrease adverse drug events by using trigger tools. Their work contributes to further development of prevention strategies. I never imagined that one of the most difficult tasks in the publication process would be selecting the papers to feature on our cover. There are so many that equally deserve the spotlight. I hope this will continue to challenge me with each issue. The information, achievements, risk reduction strategies, lessons learned, and individual perspectives are integral pieces to improving patient safety for all. This journal is one avenue to share these valuable resources freely with others. If you have research, improvement initiatives, or perspectives that contribute to our collective knowledge, please consider submitting your next manuscript to Patient Safety at patientsafetyj.com. Wishing you and yours the most joyous holiday season!

ABOUT PATIENT SAFETY As the journal of the Patient Safety Authority, committed to the vision of “safe healthcare for all patients,” Patient Safety (ISSN 2689-0143) is fully open access and highlights original research, advanced analytics, and hot topics in healthcare. The mission of this publication is to give clinicians, administrators, and patients the information they need to prevent harm and improve safety—including evidence-based, original research; editorials addressing current and sometimes controversial topics; and analysis from one of the world’s largest adverse event reporting databases. We invite you to submit manuscripts that align with our mission. We’re particularly looking for well-written original research articles, reviews, commentaries, case studies, data analyses, quality improvement studies, or other manuscripts that will advance patient safety. All articles are published under the Creative Commons Attribution – Noncommercial license, unless otherwise noted. The current issue is available at patientsafetyj.com. The patient is central to everything we do. Patient Safety complies with the Patients Included™ journal charter, which requires at least two patient members on the editorial board; regular publication of editorials, reviews, or research articles authored by patients; and peer review by patients. This publication is disseminated quarterly by email at no cost to the subscriber. To subscribe, go to patientsafetyj.com.

While working in healthcare has always carried an inherent amount of danger, I can tell you with certainty that the last time I was a staff nurse (in the spirit of transparency—it’s been a while) I never once feared going to work. The worst thing that might happen to me on my shift was a patient spitting their applesauce at me while I tried to give them their medications. I never worried about getting shot, stabbed, beaten, or raped. Violence toward our workforce is unacceptable and is one of the most pressing issues of our time. The International Association for Healthcare Security and Safety Foundation’s (IAHSSF) 2019 Healthcare Crime Survey showed assault rates of 11.7 per 100 beds, the highest since IAHSSF began collecting this data in 2012. The report also showed an all-time high rate of disorderly conduct (e.g., disturbing the peace, use of profanity) of 45.2 per 100 beds.1 The U.S. Bureau of Labor and Statistics reported that 16,890 private industry workers experienced nonfatal trauma from workplace violence in 2016, with 70% of these workers from the healthcare and social assistance industry.2 Keep in mind, this is only what gets reported. One study in Michigan showed the rate of injury among healthcare workers was up to three times higher than what was reported by the Bureau of Labor and Statistics.3 Another study from two large health systems in North Carolina and Texas showed 50.4% of respondents experienced type 2 violence—physical assault, physical threat, and verbal abuse—during their careers, and 39% of respondents experienced the same in the previous 12 months. Only 19% of these incidents were reported into their formal reporting structure, and 38% of thesthese workplace violence victims feared for their safety.4 Think about that for a moment—38% of respondent victims are working in fear. If staff are constantly worried about their own physical safety, and that of their coworkers and patients, how can they be expected to concentrate during a 12-hour shift? Studies show exposure to violence impacts healthcare workers and leads to missed time, burnout, decreased productivity, and an overall reduction in job satisfaction.5,6,7 This is nothing less than a crisis. Tackling Violence So, what can we do? There are no easy answers. Violence in our society is a multifactorial problem that requires broad-based intervention. Research on reducing workplace violence is limited or difficult to find. One recent study, conducted by the College of Human Medicine at Michigan State University, examined seven hospitals’ efforts to standardize workplace violence reporting and prioritize areas of risk using a risk matrix strategy.10 The next phase observed the ability of specific interventions to reduce workplace violence. Key takeaways included: specific unit-level data was provided to each intervention group; unitlevel action planning reflected guidelines from the Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control, National Institute for Occupational Safety and Health (CDC, NIOSH); and, while the incidence rate of events and injuries did not show a decrease from baseline in the intervention group, the control group did show a significant increase in incidence rate of post-intervention events and injuries.11 While this study makes an important contribution to the field, more research must be done. A lot more. This, however, cannot be an excuse for inaction. Hospitals, communities, and legislators will have to work together to even begin to make a dent. There are numerous resources available for hospitals through sources such as OSHA, professional societies, and local and state law enforcement agencies, but their use isn’t mandated. Federal bills H.R. 1309 and S. 851, the Workplace Violence Prevention for Health Care and Social Service Workers Act, which would require certain healthcare facilities to develop and implement workplace violence prevention plans, were introduced on February 19, 2019, and March 14, 2019, respectively; despite bipartisan support, both sit in committee.8,9 Several bills to prohibit violence against healthcare practitioners are also currently pending in Pennsylvania. These include Senate Bill 351 and House Bill 1879, which would expand current legislation to upgrade penalties for assault against all healthcare practitioners,12,13 and House Bill 39, Senate Bill 842, and House Bill 1880, which would allow healthcare employees to omit their last names from hospital ID badges.14-16 To reduce violence in healthcare, we must also address violence in the community. Just as healthcare doesn’t stop at the hospital exit, our societal problems don’t stop at the entrance. One relatively simple but critical starting point may be partnering with key stakeholders and conducting community health needs assessments (CHNAs). Interestingly, in a study of the CHNAs of 77 hospitals in 20 high-violence U.S. cities, only 32% identified violence as a high priority, and 26% of the CHNAs made no mention of violence at all. This study concludes that hospitals may not see violence as an actionable item that they can address.11 We must resolve this disconnect. Unfortunately, not all dangerous situations are avoidable. There are times that involuntary mental impairments prohibit a person from knowing they are committing an act of violence. The patient who spit their applesauce on me had advanced Alzheimer’s disease. Some patients have terrible, uncontrollable, and unpredictable reactions to general anesthesia that make them hallucinate and become violent as they awaken. Others can experience episodes of acute delirium due to disease process or medications. Those situations are not the same as willfully harming staff, including when under the influence of illegal drugs and alcohol. Someone’s accountability for their actions doesn’t stop at the point of intoxication just because they are in a hospital, the same as accountability doesn’t stop when they are behind the wheel of a car. Those patients may no longer be in control, but that should not absolve them of the consequences of their actions. We need to support our staff and hold perpetrators accountable to the full extent that the law allows. Clearly, our work is cut out for us. What practices have you put in place to reduce violence? We would love to read about your studies, your stories, and your opinions related to this critical issue. Send them to PatientSafetyJ@pa.gov.

Patient safety metrics are recurrent headlines. Intentional or not, they are often sensationalized, conflated, or misconstrued to tell a story in which patients are frequently harmed by irresponsible, negligent clinicians. The truth is far less dramatic. Although medical error does occur and real people suffer real harm, the vast majority of encounters go as expected. So it’s crucial to understand how to interpret patient safety metrics to distinguish true areas of concern from embellished front-page stories. It is also important to understand that each database has its own reporting criteria and each research study its own methodology, and while there is no universal definition for medical error, medical error is not synonymous with patient harm. Reported events do not necessarily equate to instances of medical error, nor are all instances of harm preventable. For example, a patient may have a serious allergic reaction to a medication that they have never taken previously. The Patient Safety Authority (PSA) is charged with capturing every occurrence of harm or potential harm to patients in Pennsylvania, whether attributable to medical error or not, and providing tools to prevent its recurrence. Since its inception in 2004, more than 3.8 million confidential event reports have been added to the PSA’s database, the Pennsylvania Patient Safety Reporting System (PA-PSRS)—the largest event reporting database in the United States and one of the largest in the world. The number of events reported into PA-PSRS has increased from 2004 to 2018; however, this was anticipated as a result of a maturing safety culture, and one cannot conclude from the data whether the actual number of events went up or the uptick is solely due to increased reporting. Caution should be given to inferences like “medical error is increasing” that cannot be substantiated from event reports. It may seem counterintuitive, but a facility with a low number of reports may be more concerning than one with a higher number, as this could indicate a culture where safety and transparency are not supported. What is certain is that since 2004 in Pennsylvania, the number of reported incidents (events without harm) has increased; the number of reported serious events (events with some level of harm) has not trended up or down; and the number of high- harm events (those causing life-threatening injury, irreversible harm, or death) has declined. Approximately 97% of the reports in PA-PSRS are incidents. These types of events are often overlooked in healthcare, as Pennsylvania continues to be the only state that requires healthcare facilities to report no-harm events. Incidents often indicate potential patient harm, and the difference between a “near miss” and a “serious event” may have been happenstance or an intervention not guaranteed to recur. Though PA-PSRS cannot conclusively address medical error incidence, its millions of datapoints provide insights into emerging trends that are unapparent to individual facilities. As such, it provides the framework for a larger system that transforms data into actionable information to reduce harm. Thorough ongoing analyses drive an education agenda, identify opportunities for collaborative improvement projects, and prioritize issues across Pennsylvania and the United States—in healthcare facilities and in individual practice. The PSA’s work in these areas is published and shared in Patient Safety and elsewhere, and read by healthcare providers in 49 states and 44 countries.