Pennsylvania Patient Safety Advisory
Reducing Errors in Blood Specimen Labeling: A Multihospital Initiative
The Pennsylvania Patient Safety Authority sponsored a multihospital collaborative to measure blood specimen labeling error rates, document hospital-specific interventions to reduce the labeling error rate, and measure the outcome of the interventions. The collaborative resulted in a statistically significant decrease in specimen labeling errors.
Applying the Universal Protocol to Improve Patient Safety in Radiology Services
Review of reported radiologic events in Pennsylvania identified specific processes that exposed patients to potential harm, including order and scheduling inaccuracies, patient misidentification, and inaccurate procedure verification practices. Implementation of simple system safeguards can help to mitigate this unnecessary patient risk.
Data Snapshot: Errors Involving Methotrexate
Event report analysis indicates that methotrexate dosing errors (e.g., wrong dose/overdosage, dose omission) similar to those cited in the medical literature have been occurring in Pennsylvania.
Time-Out! Wrong-Site Surgery Update
Recent event reports exemplify the value of a properly conducted time-out. In this update, Pennsylvania Patient Safety Authority emphasizes principles that should be followed during a time-out and shares results from a survey of Pennsylvania operating room managers about their time-out processes.