Journal & Resources
Pennsylvania Patient Safety Advisory
September 2006, Vol. 3, No. 3
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Patient Safety Authority Receives 2006 Eisenberg Award
The Patient Safety Authority receives the Joint Commission award in acknowledgement of the Authority's impact on patient safety on a regional level because of efforts to develop nationally recognized resource.
Skin Tears: The Clinical Challenge
Skin tears are painful, disfiguring injuries, but are preventable. Identification of risk factors, implementation of prevention strategies, and standardizing assessment and treatment can reduce the incidence of skin tears.
Letter to the Editor: Propofol Administration
A reader comments on the use of propofol for procedural sedation in the emergency department.
Letters to the Editor: Color-Coded Patient Wristbands
Readers compliment work-to-date in Pennsylvania on color-coded wristbands, recommend consideration of isolation patients, and raise the question of nationwide standardization.
Letter to the Editor: MRI Sandbags and Metal Pellets
A reader comments on the presence of metal shot in MRI sandbags.
'Sandbags' May Not Be What You Think
Sandbags containing metal pellets present an MRI hazard.
Looking Beyond the Obvious Causes of Error
Understanding the causes of medication errors requires focusing on the medication use system (e.g., obtaining patient information, communicating drug orders).
Delays in the OR: Stress Between "Running Two Rooms" and "Time Outs"
While there are many, often unavoidable reasons for delays in the operating room, addressing scheduling, transfer of care, case notification, and delays while patients are under anesthesia can help minimize the risk of procedure delays.
Getting Doctors to Report Medical Errors
A physician reporting model, DISCLOSE, addresses barriers to physician reporting.
Let's Stop this "Epi"demic!—Preventing Errors with Epinephrine
When used in error, epinephrine poses a greater risk of harm and death than other drugs. The majority of epinephrine errors involve ratio strength and look-alike names (epinephrine and ephedrine).
Foiled Again! Risk from Transdermal Patches in MRI Procedures
Foil backing on transdermal medication patches may cause tissue burns during MRI.
What the "L" is the Dose?
Certain letters and numerals (lower case letter "l" and number 1) can be interpreted different than the writer intended in medication orders, potentially resulting in medication errors.
Pressure Ulcers: A Look at Reports to PA-PSRS
Facilities may be missing opportunities to improve quality of care if they fail to assess patients for risk of developing pressure ulcers and fail to collect information about stages of any pressure ulcers that develop.
Rethinking the Routine: Aspiration of Oral Contrast Solution with Bowel Obstruction
Criteria from the American College of Radiology address diagnostic imaging studies for patients with suspected small bowel obstruction.
Disruptive Behavior and Clinical Outcomes: Perceptions of Nurses and Physicians
Disruptive behavior from nurses, physicians, and hospital administrators can put patients at risk.