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Advisories & Events
Pennsylvania Patient Safety Advisory
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Pennsylvania Patient Safety Advisory
Current Articles
Advisory Archive
March 2007, Vol. 4, No. 1
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Standardization: Autonomy versus Consensus
John R. Clarke, MD, editor, discusses this subtle yet important difference in achieving consistently good patient care systemwide.
Airway Fires during Surgery
Following safe practices can help reduce the likeliness of fires during airway surgery that involves ignition sources such as electrosurgical units.
Query on Clostridium Difficile
A reader questions the efficacy of alcohol-based hand rubs in preventing the transmission of C. difficile.
Correction to the December 2006 Advisory
In the December 2006 PA-PSRS Patient Safety Advisory, a sentence in the article “Bone Cement Implantation Syndrome” omitted a key phrase.
Helping the Authority to Help You
In December 2006 and January 2007, the Pennsylvania Patient Safety Authority hosted discussion groups of Patient Safety Officers. A full report on the discussions is available.
Safety in Using Promethazine (Phenergan)
Longstanding familiarity with promethazine may mask its potential for patient harm, such as severe tissue damage, if not administered cautiously with proper patient monitoring.
Abbreviation Gotchas
An event report includes an example of an abbreviation, HCT, that caused a patient to receive an unintended intervention.
Baxter Colleague Volumetric Infusion Pump: Product Recall Notification
Incidence of PA-PSRS reports following documented problems related to the Colleague series pumps suggests that efforts to address these problems may not have reached all clinical settings or facilities and that additional awareness may help reduce some infusion pump failures.
What's New in MRI Hazards
Two recently discovered MRI hazards and related safety strategies are discussed.
Take Steps to Avoid Inadvertent IV Administration of Nimodipine Liquid
Accidental injection of oral nimodipine for patients unable to swallow may result in severe hypotension, cardiovascular collapse, or cardiac arrest.
Complications of Retrobulbar Blocks
PA-PSRS has received reports of complications of retrobulbar blocks, including central nervous system spread of anesthesia, retrobulbar hemorrhages, respiratory arrest, and death, despite the declining use of this technique in favor of topical anesthetics.
Follow Up on Tass
An online educational program, "Get the Facts on Toxic Anterior Segment Syndrome," is available about the etiology of and care and treatment for TASS.
Skin Burns and Fires during Electroconvulsive Therapy Treatments
Understanding the potential risks associated with electroconvulsive therapy will help promote a safe treatment outcome.
