Pennsylvania HR 203: A Resolution directing the Joint State Government Commission to conduct a study of reported patient safety events and issue a report with recommendations for reducing reportable patient safety events and improving patient safety.

Bill Text

PRIOR PRINTER'S NOS. 1458, 2855 PRINTER'S NO. 3351
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE RESOLUTION
No. 203
Session of
2025
INTRODUCED BY GUZMAN, HILL-EVANS, SANCHEZ, RIVERA, CEPEDA-
FREYTIZ, MATZIE AND KHAN, APRIL 22, 2025
AS AMENDED, HOUSE OF REPRESENTATIVES, MAY 5, 2026
A RESOLUTION
Directing the Joint State Government Commission to conduct a
study of medical errors and issue a report to provide
recommendations on reduction of errors and improved patient
safety.
WHEREAS, According to the Agency for Healthcare Research and
Quality, errors can be defined as acts of commission or
omission, leading to an undesirable outcome or significant
potential for such an outcome; and
WHEREAS, Medical errors may have serious consequences such as
death, hospitalization, disability or birth defects; and
WHEREAS, According to the act of March 20, 2002 (P.L.154,
No.13), known as the Medical Care Availability and Reduction of
Error (Mcare) Act, "medical facilities," are required to report
"serious events" and "incidents"; and
WHEREAS, "Serious events" are events, occurrences or
situations involving the clinical care of a patient in a medical
facility that results in death or compromises patient safety and
results in an unanticipated injury requiring the delivery of
additional health care services to the patient; and
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WHEREAS, "Incidents" are defined as events, occurrences or
situations 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 required the delivery of
additional health care services to the patient; and
WHEREAS, Serious events and incidents may constitute an error
to the Pennsylvania Patient Safety Reporting System (PAPSRS);
and
WHEREAS, According to the Pennsylvania Patient Safety
Authority's 2024 Annual Report, there were 315,418 reports made,
which included 302,816 reports regarding incidents and 12,602
reports regarding serious events; and
WHEREAS, Some inpatient hospitals are also required to
"measure, analyze and track adverse events" and report them to
the Centers for Medicare and Medicaid Services; and
WHEREAS, All Pennsylvanians would benefit from improved
patient safety and reduced occurrences of medical errors; and
WHEREAS, The House of Representatives should craft policy
informed by a thorough understanding of how to reduce medical
errors and improve patient safety; therefore be it
RESOLVED, That the House of Representatives direct the Joint
State Government Commission to conduct a study of medical errors
and issue a report to provide recommendations on reduction of
errors and improved patient safety; and be it further
RESOLVED, That the Joint State Government Commission include
in the study processes by which medical facilities identify and
report serious events and incidents, including the processes by
which health care practitioners identify and report serious
events and incidents within their medical facilities, and
identify whether reporting is happening as prescribed by law;
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and be it further
RESOLVED, That the study evaluate how medical facilities
measure, analyze and track adverse events and how this results
in changes in practice that improve patient safety and identify
barriers to learning from reports of medical errors and barriers
to implementing changes in practice; and be it further
RESOLVED, That the study include policies adopted by other
states to reduce medical errors; and be it further
RESOLVED, That the study include best practices supported by
stakeholders such as The Hospital and Healthsystem Association
of Pennsylvania, the Pennsylvania Medical Society, the
Pennsylvania Pharmacists Association, THE PENNSYLVANIA
AMBULATORY SURGERY ASSOCIATION and the Pennsylvania State Nurses
Association; and be it further
RESOLVED, That the study include a review of the applicable
statutes and regulations related to the reduction of medical
errors and identify opportunities to enhance the same; and be it
further
RESOLVED, That the Joint State Government Commission appoint
an advisory committee to assist in this study; and be it further
RESOLVED, That the advisory committee be composed of the
following members:
(1) The Secretary of Health or a designee.
(2) One individual representing The Hospital and
Healthsystem Association of Pennsylvania.
(3) One individual representing the Pennsylvania Medical
Society.
(4) One individual representing the Pennsylvania
Pharmacists Association.
(5) One individual representing the Pennsylvania State
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Nurses Association.
(6) One individual from the Pennsylvania Patient
Advocacy Program within the Department of Health.
(7) One individual representing the Patient Safety
Authority.
(8) One licensed pharmacist