March 2010 Pennsylvania Patient Safety Advisory

Advisories & Events

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Pennsylvania Patient Safety Advisory

March 2010, Vol. 7, No. 1

201003

Reviews & Analyses

Leveraging Healthcare Policy Changes to Decrease Hospital 30-Day Readmission Rates

In 2008, there were 57,852 readmissions in Pennsylvania, amounting to approximately $2.5 billion in charges. Two major processes in healthcare facilities, if improved, can help decrease 30-day readmission rates: communication and transitional care.

Medication Errors with the Dosing of Insulin: Problems across the Continuum

In reported events involving the use of insulin products, 52% of the events led to situations in which a patient may have or actually received the wrong dose or no dose of insulin.

Communication of Radiograph Discrepancies between Radiology and Emergency Departments

When discrepant interpretations occur between the preliminary reading by an emergency department physician and the final reading by a radiologist, follow-up communication is essential to ensure that the patient has received appropriate care.

Preventing Corneal Burns during Phacoemulsification

Surgical staff must be alert to any condition that could reduce delivery of saline, because compromised irrigation can lead to corneal burns.

Other Features

Get to Know Your PSL

The Pennsylvania Patient Safety Authority’s Patient Safety Liaisons provide guidance, coordinate educational programs, encourage collaboration, and solicit feedback from healthcare facilities that report Incidents and Serious Events under Act 13 of 2002.

Editorial: the Pennsylvania Patient Safety Advisory at Seven

The Pennsylvania Patient Safety Advisory begins its seventh year of conveying educational information from the Pennsylvania Patient Safety Authority’s patient safety reporting system to healthcare providers.

Updates

Quarterly Update on the Preventing Wrong-Site Surgery Project: Digging Deeper

Analysis of events in the reporting system database focuses on trends involving local and regional anesthesia blocks, pain management procedures, ureteral stenting, and hand surgery.