Turn on more accessible mode
Turn off more accessible mode
Sign Up to Receive PSA Updates
It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again.
Sign Up to Receive PSA Updates
It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again.
Toggle navigation
menu
It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again.
Sign Up to Receive PSA Updates
Toggle navigation
menu
Sign Up to Receive PSA Updates
It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again.
Journal & Resources
PATIENT SAFETY journal
News
Training & Events
Related Organization Links
Advisory Archive
Pennsylvania Patient Safety Advisory
Advisory Archive
June 2014, Vol. 11 No. 2
Share
Download
Masthead
201406
Reviews & Analyses
Distractions in the Operating Room
Distractions can be especially dangerous during performance of complex procedures that require high levels of cognitive processing, such as those performed in the operating room. Through teamwork training and the use of preoperative briefings and surgical checklists, among other practices, the occurrence and the effects of distractions may be minimized.
Healthcare Worker Fatigue: Current Strategies for Prevention
Reports to the Pennsylvania Patient Safety Authority have indicated that working extended shifts, multiple long shifts, or without a break or meal has led to adverse events related to fatigue. Although duty hour restrictions have been the focus of most fatigue risk management programs in healthcare, additional strategies are necessary to prevent these events.
An Analysis of Reported Adverse Drug Reactions
Over a 12-month period, Pennsylvania hospitals reported 4,875 events involving adverse drug reactions (ADRs) to the Authority, with nearly 30% of these involving contrast agents. Continually assessing the types of ADRs being reported, reviewing mitigation strategies for the involved medications, and updating protocols as necessary are strategies to reduce the incidence and severity of these events.
Falls Reduction and Prevention Update: Pennsylvania Hospitals Increase Implementation of Best Practices
Collaboration participants completing an annual self-assessment survey reported an increase in full implementation for 16 of 17 categories of falls prevention practices. Participants also conducting quarterly process measures audits achieved increased compliance with falls prevention practices and reductions in rates of falls with harm.
Training Suggested When Changing Brands of Enteral Feeding Tubes
There was an increase in reports to the Authority of small-bore nasogastric feeding tube misplacements from January 2013 to October 2013 compared with the previous two years. Risk reduction strategies include staff education on feeding tube placement and verification, especially when new equipment is introduced.
Focus on Infection Prevention
Successful Strategies for Prevention of Bariatric and Colectomy Surgical Site Infections
Facilities participating in a joint collaboration of the Authority and the Pennsylvania National Surgical Quality Improvement Project achieved reductions in bariatric and colectomy surgical site infections. Additionally, the collaboration fostered success through development of a collaborative learning network and creation of comparison reports to measure progress.
Update
Quarterly Update on Wrong-Site Surgery: How to Do an Effective Time-Out in the Dark
There were 10 reports of wrong-site surgery in Pennsylvania operating rooms during the first quarter of 2014, the third consecutive quarter with 10 reports. In addition to discussing these event reports, Authority analysts describe safety processes for performing a time-out for a laser eye procedure.