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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 to be selected by the Joint
State Government Commission.
(9) One licensed registered nurse to be selected by the
Joint State Government Commission.
(10) One licensed physician to be selected by the Joint
State Government Commission.
(11) One patient safety officer from a medical facility
to be selected by the Joint State Government Commission.
(12) ONE INDIVIDUAL REPRESENTING THE PENNSYLVANIA
AMBULATORY SURGERY ASSOCIATION.
(13) Any other member the Joint State Government
Commission deems necessary;
and be it further
RESOLVED, That the Joint State Government Commission present
its report to the House of Representatives no later than 18
months after the adoption of this 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.
WHEREAS, THE PATIENT SAFETY AUTHORITY WAS ESTABLISHED UNDER
THE ACT OF MARCH 20, 2002 (P.L.154, NO.13), KNOWN AS THE MEDICAL
CARE AVAILABILITY AND REDUCTION OF ERROR (MCARE) ACT, AND IS
RESPONSIBLE FOR THE PENNSYLVANIA PATIENT SAFETY REPORTING
SYSTEM, DATA ANALYSIS, ISSUING SAFETY RECOMMENDATIONS TO MEDICAL
FACILITIES AND PROVIDING MEDICAL FACILITIES WITH PATIENT SAFETY
TRAINING OPPORTUNITIES; AND
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WHEREAS, THE MCARE ACT DEFINES A SERIOUS EVENT AS AN EVENT,
OCCURRENCE OR SITUATION 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
WHEREAS, THE MCARE ACT DEFINES AN INCIDENT AS AN EVENT,
OCCURRENCE OR SITUATION INVOLVING THE CLINICAL CARE OF A PATIENT
IN A MEDICAL FACILITY THAT COULD HAVE INJURED THE PATIENT BUT
DID NOT EITHER CAUSE AN UNANTICIPATED INJURY OR REQUIRE THE
DELIVERY OF ADDITIONAL HEALTH CARE SERVICES TO THE PATIENT; AND
WHEREAS, SERIOUS EVENTS AND INCIDENTS ARE REQUIRED TO BE
REPORTED TO THE PENNSYLVANIA PATIENT SAFETY REPORTING SYSTEM;
AND
WHEREAS, ACCORDING TO THE 2024 ANNUAL REPORT OF THE
PENNSYLVANIA PATIENT SAFETY AUTHORITY, THERE WERE 315,418
REPORTS MADE, INCLUDING 302,816 REPORTS OF INCIDENTS AND 12,602
REPORTS OF SERIOUS EVENTS; AND
WHEREAS, CERTAIN 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 PATIENT SAFETY EVENTS;
AND
WHEREAS, THE HOUSE OF REPRESENTATIVES SHOULD CRAFT POLICY
INFORMED BY A THOROUGH UNDERSTANDING OF HOW TO REDUCE REPORTABLE
PATIENT SAFETY EVENTS AND IMPROVE PATIENT SAFETY; THEREFORE BE
IT
RESOLVED, THAT THE HOUSE OF REPRESENTATIVES DIRECT THE JOINT
STATE GOVERNMENT COMMISSION TO CONDUCT A STUDY OF REPORTED
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PATIENT SAFETY EVENTS AND ISSUE A REPORT WITH RECOMMENDATIONS
FOR REDUCING REPORTABLE PATIENT SAFETY EVENTS AND IMPROVING
PATIENT SAFETY; AND BE IT FURTHER
RESOLVED, THAT THE STUDY PERTAIN ONLY TO DOCUMENTATION AND
REPORTED EVENTS ALREADY RETAINED BY THE PATIENT SAFETY AUTHORITY
SO AS NOT TO IMPOSE UNDUE COSTS ON MEDICAL FACILITIES SUBJECT TO
THIS RESOLUTION; AND BE IT FURTHER
RESOLVED, THAT THE STUDY INCLUDE AN EXAMINATION OF THE
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 MEDICAL FACILITIES, AND WHETHER THE REPORTING
POLICIES OF SURVEYED FACILITIES GENERALLY ESTABLISH REPORTING
REQUIREMENTS AS PRESCRIBED BY LAW; AND BE IT FURTHER
RESOLVED, THAT THE STUDY EVALUATE HOW MEDICAL FACILITIES
MEASURE, ANALYZE, INVESTIGATE AND TRACK ADVERSE EVENTS, HOW
THOSE ACTIVITIES RESULT IN CHANGES IN PRACTICE THAT IMPROVE
PATIENT SAFETY, AND BARRIERS TO LEARNING FROM REPORTS ISSUED BY
THE PATIENT SAFETY AUTHORITY AND IMPLEMENTING CHANGES IN
PRACTICE; AND BE IT FURTHER
RESOLVED, THAT THE STUDY INCLUDE POLICIES ADOPTED BY OTHER
STATES TO REDUCE REPORTABLE PATIENT SAFETY EVENTS; AND BE IT
FURTHER
RESOLVED, THAT THE STUDY INCLUDE BEST PRACTICES SUPPORTED BY
STAKEHOLDERS, INCLUDING 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
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STATUTES AND REGULATIONS RELATING TO THE REDUCTION OF REPORTABLE
PATIENT SAFETY EVENTS AND IDENTIFY OPPORTUNITIES TO ENHANCE
THOSE STATUTES AND REGULATIONS; AND BE IT FURTHER
RESOLVED, THAT THE JOINT STATE GOVERNMENT COMMISSION APPOINT
AN ADVISORY COMMITTEE TO ASSIST IN THE STUDY; AND BE IT FURTHER
RESOLVED, THAT THE ADVISORY COMMITTEE CONSIST 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
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 SELECTED BY THE JOINT STATE
GOVERNMENT COMMISSION.
(9) ONE LICENSED REGISTERED NURSE SELECTED BY THE JOINT
STATE GOVERNMENT COMMISSION.
(10) ONE LICENSED PHYSICIAN SELECTED BY THE JOINT STATE
GOVERNMENT COMMISSION.
(11) ONE PATIENT SAFETY OFFICER FROM A MEDICAL FACILITY
SELECTED BY THE JOINT STATE GOVERNMENT COMMISSION.
(12) ONE INDIVIDUAL REPRESENTING THE PENNSYLVANIA
AMBULATORY SURGERY ASSOCIATION.
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(13) ANY OTHER MEMBER IDENTIFIED AS BEING HELPFUL BY THE
JOINT STATE GOVERNMENT COMMISSION;
AND BE IT FURTHER
RESOLVED, THAT THE JOINT STATE GOVERNMENT COMMISSION TRANSMIT
THE REPORT TO THE HOUSE OF REPRESENTATIVES NO LATER THAN 18
MONTHS AFTER THE ADOPTION OF THIS RESOLUTION.
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