Journal & Resources
Pennsylvania Patient Safety Advisory
September 2010, Vol. 7, No. 3
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Reviews & Analyses
Adverse Drug Events with HYDROmorphone: How Preventable are They?
Gaps exist in healthcare providers’ understanding of the efficacy and potency of HYDROmorphone, as evidenced by medication errors and adverse drug reactions reported in Pennsylvania.
Diagnostic Error in Acute Care
Misdiagnosis-related harm is preventable. Healthcare facilities have many strategies at their disposal that can help reduce diagnostic error rates.
Hemodialysis Administration: Strategies to Ensure Safe Patient Care
Without attention to patient safety and error prevention, even a well-established procedure like hemodialysis can result in an adverse event.
Strategies for Avoiding Problems with the Use of Pneumatic Tourniquets
Failure or misuse of pneumatic tourniquets can lead to muscle ischemia, nerve damage, convulsions, and coma. Addressing cuff availability and educating staff about cuff selection, application, and inflation pressure are fundamental strategies to avoid complications.
Focus on Infection Control
Demonstrating Return on Investment for Infection Prevention and Control
Investing in an effective infection control program can have a profound positive impact on a healthcare organization’s bottom line and reputation, prevent catastrophic healthcare-associated infections, and improve patient safety.
Updates
Quarterly Update on the Preventing Wrong-Site Surgery Project
Three years have passed since the first definitive article from the Pennsylvania Patient Safety Authority on wrong-site surgery. After that initial focus on wrong-site surgery, the number of events has decreased each year. Facilities reported 14 events during the last quarter (April through June 2010).
Other Features
Satisfying Educational Needs with the Pennsylvania Patient Safety Authority Web Site
Southwest Patient Safety Liaison, Robert A. Yonash, RN, promotes the Pennsylvania Patient Safety Authority Web site as a thorough repository of patient safety resources and education for patient safety officers.
Corrections
Correction: Beyond the Bundle: Reducing the Risk of Central Line-Associated Bloodstream Infections
This article contained incorrect calculations that need correction about the Pennsylvania hospitals that reported central line-associated bloodstream infections through the National Healthcare Safety Network from July 2008 through March 2009.
Correction: Medication Errors: Significance of Accurate Patient Weights
This article contained incorrect answer choices in question one of the self-assessment questions.