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Advisories & Events
PATIENT SAFETY journal
News
Training & Events
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Advisory Archive
Pennsylvania Patient Safety Advisory
Advisory Archive
September 2015, Vol. 12, No. 3
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201509
Reviews & Analyses
Delirium: Patient Safety Event Reporting and Strategies to Improve Diagnosis, Prevention, and Treatment
The Pennsylvania Patient Safety Authority identified a nearly seven-fold increase in the number of delirium-associated events reported over the past decade. A common syndrome in hospitalized adults, delirium has been recognized as a hospital-acquired condition that can result in serious harm to patients.
Medication Errors Affecting Pediatric Patients: Unique Challenges for This Special Population
Of the more than 4,000 pediatric medication errors analyzed, nearly 18% of the reported events reached the patient and either caused harm or required additional monitoring to preclude harm. While most events mentioned challenges similar to those encountered in providing medications to adults, the resulting harm can be more severe in pediatric patients.
Pregnancy-Related Unplanned Returns to the Operating Room
Complications or untoward outcomes related to the procedures undergone by pregnant women can result in unplanned returns to the operating room. Analysis of 1,031 reports of these events identified the most common types as induced abortion and postpartum hemorrhage.
The Current State of “Wrong Patient” Insulin Pen Injections
Pennsylvania data and national reports illustrate that unsafe practices with the use of insulin pens place patients at risk of bloodborne pathogen transmission. Hospitals are encouraged to collect and analyze their own wrong-patient insulin pen events and closely examine their current insulin practices.
Focus on Infection Prevention
Antimicrobial Therapy for Pneumonia in Pennsylvania Long-Term Care: A Spotlight on Culture
Based on events reported to the Authority, antimicrobial treatment for pneumonia in Pennsylvania long-term care facilities seems to be guided by diagnostic criteria sets, empiric therapy algorithms, and clinician experience rather than by culture data. Culture data and laboratory-guided antimicrobial therapy are necessary for optimal antibiotic use.
Updates
Quarterly Update on Wrong-Site Surgery: Eleven Years of Data Collection and Analysis
Twenty-one wrong-site surgery events were reported in the last quarter of the 2014-2015 academic year, including five wrong-site anesthesia blocks, five wrong-site procedures, five misidentified spinal levels, and three wrong-side procedures.
Identify Sufficient Supplemental Oxygen for Patient Intrahospital Transport
Determining whether the amount of oxygen in a tank is adequate can avert transporting a patient with an insufficiently filled oxygen tank. Calculations can be performed using formulas, look-up tables, or calculator applications available both online and as mobile apps.
Other Features
The 160-Pound Computer That Can Be Mass-Produced by Unskilled Labor
The contributions of technology are integral and essential in healthcare delivery. However, when protocols are insufficient for the tasks at hand and technologies malfunction, it is the human element that we rely on to adapt.
