September 2009 Pennsylvania Patient Safety Advisory

Advisories & Events

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Pennsylvania Patient Safety Advisory

September 2009, Vol. 06, No. 3

200909

Reviews & Analyses

Medication Monitoring Errors: Inappropriate Levofloxacin Doses

Levofloxacin, which requires dosage adjustments based on renal function, is the medication most frequently involved in reports to the Authority about errors involving drug-related clinical monitoring.

Connecting Remote Cardiac Monitoring Issues with Care Areas

Remote cardiac monitoring alone does not ensure patient condition changes are successfully communicated to appropriate healthcare providers.

Epidural or Subarachnoid Catheter Shear

Under certain conditions, an epidural or subarachnoid catheter can shear, leaving a fragment in the patient.

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.

Safe Patient Outcomes Occur with Timely, Standardized Communication of Critical Values

Despite the importance of critical values in patient care and requirements to identify and promptly communicate critical results, there is little standardization of procedures.

Other Features

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.

Collaborative Patient Safety Effort: Addressing Phlebotomy Specimen Mislabeling

Patient Safety Liaison Megan Shetterly, RN, MS, highlights a collaborative in Pennsylvania to identify steps and system redesigns to reduce and eventually eliminate opportunities for phlebotomy specimen mislabeling.

Focus on Infection Control

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.

Updates

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.

Improvement in Preventing Wrong-Site Surgery! Traction or Transient?

There was an encouraging decrease in the number of reports of wrong-site surgeries for the third consecutive quarter to an all-time low of six reports.