Pennsylvania Patient Safety Advisory
Errors in Radiation Therapy
Although rare, radiation therapy errors can result in devastating and sometimes fatal injuries, especially when misadministration results in injury to vital organs or structures.
Editorial: None Is Perfect
There are lessons to be learned from recent, adverse experiences in a model healthcare system that made nationwide news, not the least of which is that patient safety is an integral part of the reliable delivery of quality healthcare and of quality improvement.
Barriers to Urinary Catheter Insertion and Management Practices
Catheter-associated urinary tract infections (CAUTIs) remain among the most predominant healthcare-acquired infections in the United States. This article discusses the Authority’s survey of infection preventionists to measure implementation of CAUTI prevention practices in Pennsylvania hospitals.
An Update on the “Epi”demic: Events Involving EPINEPHrine
Analysts revisit medication errors involving EPINEPHrine because events reported to the Pennsylvania Patient Safety Authority indicate that different types of errors occur with EPINEPHrine, many with the potential to cause patient harm.