Drug Labeling and Packaging—Looking Beyond What Meets the Eye
The design of medication packaging and labeling can contribute to errors such as incorrect drug dispensing. Factors such as readability, expression of drug strength or concentration, use of color, and lack of contrast can all affect the potential for an error to occur.
Query on Wrong-Site Surgery
A reader questions whether the analysis of wrong-site surgery events reported in Pennsylvania and the resulting article adequately addresses the responsibility of physicians in preventing wrong-site surgery.
Profitability is Associated with Reporting Patient Safety Events
There is a small, yet significant relationship between the number of reports per licensed bed of an acute care hospital and its operating margin, according to analysis of reports submitted to PA-PSRS and the Pennsylvania Health Care Cost Containment Council’s 2006 financial report.
Preventing Adverse Events Related to Chest Tube Insertion
A tutorial program for physicians that discusses four sources of adverse outcomes during chest tube insertion (e.g., incorrect surgical technique) is available from the U.S. Agency for Healthcare Research and Quality. Examples of these sources of adverse outcomes are apparent in reports to PA-PSRS.
Deaths Following Ambulatory Surgery
Analysis of reports of patient deaths following ambulatory surgery emphasizes the need for ambulatory surgical facilities to be able to respond to emergency conditions.
The Big Picture
Janet Johnston, RN, MSN, JD, retires from her position as a PA-PSRS patient safety analyst and shares her insight on the importance of recognizing the relationship between individual health-related tasks and the patient’s overall care.