Patient Safety Authority Update
Five years after the release of the seminal report, To Err is Human, and six months after the start of PA-PSRS, how are Pennsylvania facilities responding to patient safety?
Risk of Unnecessary Gall Bladder Surgery
Event reports discuss attempted cholecystectomy procedures in patients who had previously had their gall bladders removed; these previous procedures did not become known until the patients' surgeries were performed.
Reported scissors-related injuries include superficial nicks, lacerations, and even a case of amputation of a finger tip; lessons learned focus on avoidance, assessment, use of blunt instruments, visibility, control, and positioning.
Follow-up on Previous Advisory Articles
Patient Safety Officers share feedback and follow-up on two topics of previous Advisory issues (i.e., insulin and tuberculin syringe confusion, time out processes).
Fetal Lacerations Associated with Cesarean Section
Several interventions may reduce the risk of fetal laceration associated with Cesarean section, including use of blunt instrumentation, moving the uterine wall away from the fetus before incision, and removing abdominal wall retractors before delivery.
Early Discharge from the ED
Event reports discuss patients who were discharged too soon after presenting to the emergency department with poisoning, perhaps due to cognitive bias on the part of clinicians.
A Word About Air Detection Devices
Air detection devices are not foolproof systems and cannot be relied upon solely to prevent air embolism associated with contrast media injectors.