Pennsylvania Patient Safety Advisory
Family Members Advocate for Improved Identification of Patients with Dementia in the Acute Care Setting
A patient’s family member contacted the Pennsylvania Patient Safety Authority about several “near miss” patient safety events in which hospital staff obtained inaccurate information from the patient, unaware of his dementia diagnosis. Risk reduction strategies targeting failure modes include screening for dementia, assessing capacity, identifying and communicating with surrogate decision makers, and standardizing communication of a patient’s diagnosis with all hospital staff.
Missed Respiratory Therapy Treatments: Underlying Causes and Management Strategies
Events reported to the Pennsylvania Patient Safety Authority and a statewide survey of respiratory therapists provided a foundation to understand why missed respiratory treatments occur. Tracking the reasons for missed treatments is the first step to better understand facility-based trends and may guide managers as they consider methods to coordinate care and develop time-driven standards.
Medication Errors Involving Healthcare Students
The extent to which healthcare students are involved in medication errors is relatively unexplored. Professional organizations, healthcare facilities, and professional schools can help reduce the risk of student-involved errors by implementing key strategies, including incorporation of didactic and experiential medication safety content into school curricula and on-site training programs.
The Forgotten Tourniquet—An Update
Since the Authority first reported on tourniquet events and prevention strategies in 2005 and 2010, Pennsylvania hospitals continue to report events in which a tourniquet is left on a patient after procedures such as IV insertion, phlebotomy, and extremity surgery.
Authority-Recognized Healthcare Providers are Committed to Patient Safety
The Pennsylvania Patient Safety Authority’s annual I Am Patient Safety contest promotes individuals and groups within Pennsylvania’s healthcare facilities who have demonstrated an exceptional commitment to patient safety. The Authority congratulates the individuals recognized for their efforts to improve patient safety in Pennsylvania’s healthcare facilities, and applauds their commitment.
More than Complicated, Healthcare Delivery is Complex, Adaptive, and Evolving
Individuals, or organizations, prioritize their improvement efforts by their needs, goals, and resources. The inherent paradoxes are inevitable and challenging but also offer opportunities for creative problem solving and advances as we strive to provide the safest and best healthcare possible for our patients.