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Advisories & Events
Pennsylvania Patient Safety Advisory
News
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Pennsylvania Patient Safety Advisory
Current Articles
Advisory Archive
September 2008, Vol. 5, No. 3
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Reviews & Analyses
Medication Errors Associated with Documented Allergies
A review of data from PA-PSRS reveals more than 3,800 reports in which medications were erroneously prescribed for and given to patients who had documented allergies to them.
Anticoagulation Management Service: Safer Care, Maximizing Outcomes
Healthcare organizations have increasingly recognized the benefits of anticoagulation services in the inpatient and outpatient settings.
Triage of the Obstetrics Patient in the Emergency Department: Is There Only One Patient?
Optimal management of two patients requires a systematic approach and open communication between the emergency department and obstetrics department.
Malignant Hyperthermia: Is Your Facility Prepared to Treat This Rare Condition?
While occurrence of malignant hyperthermia is rare, the need for rapid response requires planning and advance preparation.
Hazardous Spills: The Safe Handling of Hazardous Drugs
Safe handling of hazardous drug spills is different from other healthcare spills. Exposure extends beyond patients and healthcare practitioners because nonclinical staff are often involved with containment and disposal.
Other Features
Leadership Series: UPMC’s Experience with Disclosure of Medical Errors
At the University of Pittsburgh Medical Center (UPMC), physicians keep lines of communication open and remain available and accessible to their patients after medical errors occur that result in harm.
Editorial: WHO Surgical Safety Checklist
The Second Global Patient Safety Challenge: Safe Surgery Saves Lives initiative introduced this checklist, designed to catch omissions in the actions supporting an operation before the patient suffers harm.
Focus on Infection Control
Hand Hygiene Practices and the Use of Alcohol-Based Sanitizers
Use of alcohol hand sanitizers appears to be superior to traditional handwashing when the caregiver’s hands are not visibly soiled.
From the Database
Rapid Response in the Operating Room
Rapid response teams have proven effective for hospitalized patients in distress outside of critical care areas.
Other Patient Safety Information
Forcing Functions of Antibiotic Prophylaxis
Introducing certain forcing functions can help improve physician behavior associated with use of prophylactic antibiotics in preventing surgical site infections, according to a program undertaken at Temple University Hospital.
Updates
Quarterly Update on the Preventing Wrong-Site Surgery Project
Previous wrong-site surgery data has been updated according to information submitted during the last quarter (Q2-2008).
Still Not Seeing Clearly—A Second Look at Intraocular Lens Implant Events
This follow-up article looks at the frequency of incorrect IOL placement reports submitted since the inception of PA-PSRS. Process issues point to team effort as being a key factor in reducing the incidence of wrong IOL implantation.
