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Pennsylvania Patient Safety Advisory
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Advisory Archive
June 2007, Vol. 4, No. 2
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200706
Safety Leadership
A Pennsylvania healthcare leader addresses the important connection between an organization’s leadership and the success of the organization’s safety program.
Doing the Right Things to Correct Wrong-Site Surgery
Wrong-site surgery that touches the patient is expected to occur once a year in the operating room of a 300-bed hospital. Considering wrong-site surgery prevention processes as a whole is an important strategy to preventing wrong-site surgery.
Authority Expands Focus on Education, Collaboration, and More with Strategic Plan
The Pennsylvania Patient Safety Authority releases a strategic plan of initiatives to be implemented during the next several years.
Mismanagement of Expressed Breast Milk
Ensuring consistent delivery of the correct mother’s expressed breast milk (EBM) to the correct infant is a challenge; mismanagement of EBM can upset family and staff about the potential risk to the infant.
Propofol Infusion Syndrome: A Rare but Potentially Fatal Reaction
This complex syndrome, associated with factors such as high doses of propofol, warrants attention to identify its mechanism, patients who are at risk, and methods of prevention.
Fentanyl Transdermal System: Taking Another Look
Errors involving these patches, such as multiple patches inadvertently applied, have resulted in significant patient harm.
Strategies to Minimize Vascular Complications following a Cardiac Catheterization
Cardiologists and nurses have an important role in the early detection and management of complications associated with cardiac catheterizations.
Going Beyond the Simple Fix
A facility identifies and implements changes in response to a near miss, then continues to look for system improvement opportunities.
In Vitro Hemolysis: Delays May Pose Safety Issues
Understanding the causes of in vitro hemolysis and corrective strategies to prevent it can help ensure that a quality specimen is obtained for analysis.
