Pennsylvania Patient Safety Advisory
Omission of High-Alert Medications: A Hidden Danger
More than 2,700 drug omission errors involving more than 500 different medications were reported through PA-PSRS from January 1 through April 30, 2013. Risk reduction strategies include developing a consistent administration process for intravenous (IV) medication setup, tracing IV lines, and using healthcare technology well.
Decision Tree Helps Standardize Reporting of Falls Event Types
Toileting-related falls may occur more often than the current PA-PSRS data shows. Standardizing the assignment of falls event types provides a clearer picture of the circumstances surrounding inpatient falls, improves the reliability and validity of data, and better informs falls prevention programs.
A Systems and Behavioral Approach to Improve Hand Hygiene Practice
Mapping specific interventions to internal and external motivators of behavior can improve healthcare worker hand hygiene performance. A multimodal framework of system and behavioral strategies is vital to investigate, understand, and mitigate gaps in hand hygiene compliance.
A Change in Clinical Direction
The Pennsylvania Patient Safety Authority welcomes Ellen S. Deutsch, MD, MS, FAAP, FACS, as clinical director and editor and discusses potential enhancements to the Pennsylvania Patient Safety Advisory.