March 2012 Pennsylvania Patient Safety Advisory

Advisories & Events

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Pennsylvania Patient Safety Advisory

March 2012, Vol. 9, No. 1

201203

Reviews & Analyses

Violence Prevention Training for Emergency Department Staff

A comprehensive violence prevention program is necessary to promote a safe environment for patient care in the emergency department. Mandatory training for staff is one gap in violence protection practices identified by a Pennsylvania Patient Safety Authority survey.

Colonoscopy-Associated Perforation: Systematic Review and Meta-Analysis of Incidence and Risk Factors

Despite the widespread use of colonoscopy and the seriousness of bowel perforation, information on risk factors, especially modifiable risk factors, is limited.

Medication Errors: When Pharmacy Is Closed

Pennsylvania healthcare facilities have reported more than 500 medication errors to the Pennsylvania Patient Safety Authority that imply an event occurred while the pharmacy department was closed (e.g., wrong-drug errors).

Survey of Ambulatory Surgical Facility Preoperative Screening Processes in Pennsylvania

To inform its ambulatory surgical facility (ASF) collaboration in the northeast region of Pennsylvania, the Pennsylvania Patient Safety Authority surveyed Pennsylvania ASFs about presurgical screening and assessment processes and the frequency of ASF transfers and cancellations.

Focus on Infection Prevention

Pennsylvania: On the CUSP of Measuring Infection Prevention Culture

Pennsylvania intensive care units participating in the On the CUSP: Stop Blood Stream Infection project have realized improved compliance with best practices and experienced an 8% decrease in central line utilization.

From the Database

Data Snapshot: Death Rate among CUSP Facilities

Pennsylvania Patient Safety Authority analysts noted a decrease in deaths reported in event reports of central-line associated bloodstream infections (CLABSI) among Pennsylvania critical care units participating in the Comprehensive Unit-based Safety Program, regardless of whether the death was attributable to CLABSI.

Update

Quarterly Update on Preventing Wrong-Site Surgery

In this update, Pennsylvania Patient Safety Authority analysts discuss the direction of the Authority’s wrong-site surgery project, including upcoming recommendations, the incidence of anesthetic blocks and ureteral stent insertions, informative near-miss reports, how to prevent misinformation from the surgeon’s office, and operating room culture of safety.

Other Features

Partnership for Patients

Senior Patient Safety Liaison, Christina Hunt, RN, MSN, MBA, HCM, discusses how the Pennsylvania Patient Safety Authority will support Pennsylvania hospitals in achieving Partnership for Patients’ goals of reducing preventable healthcare-acquired conditions and readmissions.