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Advisories & Events
Pennsylvania Patient Safety Advisory
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Pennsylvania Patient Safety Advisory
Current Articles
Advisory Archive
June 2010, Vol. 7, No. 2
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201006
Reviews & Analyses
Improving the Safety of the Blood Transfusion Process
Transfusion of blood components is a complex process involving multiple departments, staff members, and steps. Accurate recipient identification at blood collection and administration is essential to the safety of the total blood transfusion process.
Tubing Misconnections: Making the Connection to Patient Safety
Whenever patients have multiple tubing lines connected to them, the potential for tubing misconnections increases. Liquid-to-liquid and liquid-to-gas misconnections can pose the most serious harm to patients.
Safeguarding the Storage of Drug Products
Reported events describe how storage of medications in locations including the pharmacy, patient care areas, automated dispensing cabinets, and anesthesia carts have contributed to drug product mix-ups.
Clinical Emergency: Are You Ready in Any Setting?
Three factors of rapid response preparedness must be addressed in clinical care areas: (1) rapid access to functioning equipment and up-to-date supplies, (2) knowledgeable and trained staff, and (3) maintaining a state of readiness.
Other Features
Probiotic Use for Clostridium Difficile Infection
Pennsylvania Patient Safety Authority analysts summarize results of their review of the clinical literature to determine the efficacy of probiotics for the prevention and treatment of gastrointestinal illness, including Clostridium difficile infection.
Other Patient Safety Information
OR Fire Prevention Video Available
The Anesthesia Patient Safety Foundation offers a free video on its Web site that promotes best practices regarding the prevention of surgical fires in the operating room.
Focus on Infection Control
Management of MRSA in Ambulatory Surgical Facilities
Pennsylvania ambulatory surgical facilities (ASFs) are required to develop and implement an internal infection control plan that includes procedures for identifying and designating patients with methicillin-resistant Staphylococcus aureus (MRSA). In response to requests from ASFs in Pennsylvania, the Pennsylvania Patient Safety Authority conducted a series of MRSA management workshops.
Updates
Quarterly Update on the Preventing Wrong-Site Surgery Project
Pennsylvania Patient Safety Authority analysts identified eight hospitals that dramatically reduced their incidence of wrong-site surgery reports. The Authority interviewed the Patient Safety Officers or other personnel at these facilities to identify their successful efforts to eliminate wrong-site surgery.
