December 2006 Pennsylvania Patient Safety Advisory

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Pennsylvania Patient Safety Advisory

December 2006, Vol. 3, No. 4

200612

Remain Steadfast in Patient Safety Efforts

The Patient Safety Authority administrator discusses the growth of the Patient Safety Advisory with each successive issue and encourages Pennsylvania healthcare facilities to continue to use the Advisory and other associated resources to improve patient safety.

Bone Cement Implantation Syndrome

Bone cement implantation syndrome is a well-recognized complex of sudden physiologic changes that occur within minutes of the use of methyl methacrylate cement.

Perforations of the Colon during Colonoscopies

John R. Clarke, M.D., Clinical Director of PA-PSRS, invites providers who perform colonoscopies to participate in a statewide safety initiative to reduce the risk of colon perforations during colonoscopy.

Oxygen-Enriched Environments Increase the Fire Risk from Alcohol-Based Hand Sanitizers

Clinicians who use alcohol-based hand sanitizers in oxygen-enriched environments (e.g., operating rooms) can engage in safe practices to reduce the risk of fire.

Purple Glove Syndrome

An invited specialist comments on purple glove syndrome, an adverse drug reaction related to intravenous administration of phenytoin (DILANTIN).

Keeping an Eye on Toxic Anterior Segment Syndrome

Toxic anterior segment syndrome (TASS) is a rare complication of intraocular surgery that can nevertheless cause permanent injury to the eye.

I'm Stuck and I Can't Get Out! Hospital Bed Entrapment

Entrapment involves a patient who is caught, trapped, or entangled in the bed system (e.g., bed rails). Bed rails are beneficial, but misuse can place patients at significant risk.

Confirming Feeding Tube Placement: Old Habits Die Hard

Clinicians can avoid less reliable methods to confirm feeding tube placement in favor of evidence-based methods. Risk reduction strategies may help guide clinicians in minimizing feeding tube misplacement.

Let's Stop the Bleeding: Preventing Errors with Heparin Therapy

Heparin is a high-alert medication that warrants unique handing during prescripting, dispensing, and administration.