Pennsylvania Patient Safety Advisory
Prescribing Errors that Cause Harm
Errors that occur in the prescribing phase of the medication use process are less likely to reach the patient due to the opportunity to intercept them. However, some errors do make their way through the entire process and cause harm.
Process Assessment is Key to Prevention of Certain Ophthalmology Events
Events have steadily increased in Pennsylvania, and there is the opportunity to evaluate processes to prevent the potential for these events. Active participation by engaged staff in the execution of the Universal Protocol and use of an ophthalmology-specific perioperative checklist remain the recommended best practices.
Blood Transfusion Events—Lessons Learned from a Complex Process
Although not all transfusion-related events are caused by errors, this complex process has many critical decision points at which errors can occur. Advances in donor screening; improved testing of the blood supply; emerging technology, such as barcoding; and improvements in transfusion medicine practices have been found to increase the safety of blood transfusion.
Early Detection of Sepsis in Pennsylvania’s Long-Term Care Residents
With a mortality rate of 15% to 30%, sepsis is the leading cause of death from infection in the United States. Despite the prevalence of sepsis and its serious consequences, awareness remains low, and sepsis is frequently under-diagnosed early, when it is still potentially reversible.
Checklists: The Good, the Bad, and the Ugly
Attention to both the small details and the big picture of creating and implementing checklists can be used to optimize their helpful aspects and minimize counterproductive components.
Saves, System Improvements, and Safety II
This recurring feature highlights successes of healthcare workers in keeping patients safe; in this case, correcting a surgical site-marking error before harm occurred.