June 2009 Pennsylvania Patient Safety Advisory

Advisories & Events

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Pennsylvania Patient Safety Advisory

June 2009, Vol. 6, No. 2

200906

Reviews & Analyses

Beyond the Count: Preventing the Retention of Foreign Objects

Surgical counts are intended to prevent the retention of a sponge, sharp, or instrument during a surgical procedure, yet despite the highly regulated nature of the process, discrepancies in the surgical count occur.

Medication Errors Occurring in the Radiologic Services Department

The complexity of the procedures, the use of high-alert medications, and the risk of communication failures during handoffs can contribute to medication errors in the radiologic setting.

Uterine Perforation Associated with Minimally Invasive Gynecologic Procedures

Uterine perforation is a known risk of minimally invasive gynecologic procedures, and the physician must thoroughly evaluate patients to identify who is at risk.

Safety in the MR Environment: Ferromagnetic Projectile Objects in the MRI Scanner Room

To avoid serious or fatal injury from projectiles, magnetic resonance personnel must understand the principles of the projectile effect and properly screen individuals before entering the scanner room for ferromagnetic objects.

Other Features

Enhancing Patient Safety through Education and Collaboration

Patient Safety Liaison Megan Shetterly, RN, MS, discusses a common theme among Patient Safety Officers in the Northeast Region.

Focus on Infection Control

Successful Reduction of Ventilator-Associated Pneumonia

Two Pennsylvania hospitals share success strategies associated with implementation of the Institute for Healthcare Improvement’s ventilator bundle.

Updates

Quarterly Update on the Preventing Wrong-Site Surgery Project

Twelve wrong-site surgeries were reported during the first quarter of 2009 (Q1-2009). In this update, analytical commentary accompanies the report accounts to emphasize previously discussed principles of preventing wrong-site surgery.

Other Patient Safety Information

Patient Safety in Pennsylvania Healthcare Facilities

The Pennsylvania Patient Safety Authority invited patient safety officers from all reporting facilities in Pennsylvania to participate in a survey initiative to measure the level of adoption of selected safety practices.