Patient Safety Trends in 2023: An Analysis of 287,997 Serious Events and Incidents From the Nation’s Largest Event Reporting Database

Abstract

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, with over 4.7 million acute care event reports dating back to 2004. In this article, we analyze the patient safety event reports submitted to PA-PSRS in 2023. We extracted data from PA-PSRS and obtained data from the Pennsylvania Health Care Cost Containment Council (PHC4). Report counts are based on report submission date, and rates are based on event occurrence date and calculated per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs). In 2023, 287,997 reports were submitted to PA-PSRS, which is a considerable increase from 2022 but very close to the 2021 total. Reports of serious and high harm events increased by 20.6% and 25.0%, respectively, representing the largest annual increases historically. Of the 287,997 reports, 96.0% were from hospitals, 3.8% were from ambulatory surgical facilities, and 0.2% were from birthing centers and abortion facilities. The vast majority (95.9%) of the 2023 reports were incidents, with the remaining 4.1% classified as serious events. The reporting rate based on event occurrence date for hospitals in the first half of 2023 was 30.0 reports per 1,000 patient days; for ASFs, the rate was 9.9 reports per 1,000 surgical encounters. For each of the past five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, which accounted for 33.1% of acute care event reports submitted in 2023. From a distribution perspective, the greatest increase in percent of total reports in 2023 occurred with event type Medication Error, and the greatest increase for serious events was with event type Complication of Procedure/Treatment/Test (P/T/T). Almost half of the increase in Complication of P/T/T was with subtype Complication following surgery or invasive procedure (48.2%; 968 of 2,009), and 54.6% (529 of 968) of reports in this subtype were due to unplanned returns to the operating room. The number of total reports, serious events, and high harm events, as well as preliminary reporting rates for hospitals and ASFs, all increased in 2023. Patient Safety Authority will continue working with Pennsylvania healthcare facilities to support high-quality reporting and patient safety practices.