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Pennsylvania Patient Safety Advisory
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Pennsylvania Patient Safety Advisory
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Advisory Archive
Most Recent Advisory
September 2017, Vol. 14, No. 2
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201709
Reviews & Analyses
Treating Hyperkalemia: Avoid Additional Harm When Using Insulin and Dextrose
Hyperkalemia is a fairly common, potentially life-threatening electrolyte disturbance encountered in hospitalized patients. Treatment of hyperkalemia with insulin and dextrose, without implementing clear protocols and error-reduction strategies, can lead to hypoglycemia and other patient harm.
Promote a Culture of Safety with Good Catch Reports
A hospital good catch program can be an effective means to improve patient safety. Recognizing and rewarding staff can encourage good catch submissions and provide more opportunities to improve patient safety.
Focus on Infection Prevention
Optimal Use of Antibiotics for Urinary Tract Infections in Long-Term Care Facilities: Successful Strategies Prevent Resident Harm
The intensity of antibiotic use to treat urinary tract infections (UTI) in LTCF increases the risk for life threatening adverse effects. This crisis of incorrect antibiotic use and its downstream effects demonstrates an urgent need for immediate adoption of best practices for accurate identification and optimal treatment of UTI in the elderly.
Legionella: Could This Potentially Deadly Bacteria Be Lurking in Your Facility’s Water Distribution System?
Preventing healthcare-acquired legionnaires’ disease depends upon identifying possible sources where Legionella growth could occur and instituting control measures. Evidence-based risk reduction strategies may control and proactively prevent healthcare-acquired legionellosis.
From the Database
Data Snapshot: Dislodged Tubes and Lines
Feeding tubes, intravascular catheters, and other tubes and lines are routinely and safely used in healthcare, but tubes or lines that become dislodged can have fatal consequences, depending upon the type of tube or line used and how quickly the dislodgement is recognized and treated.
Other Features
Workarounds: Trash or Treasure?
An enlightened understanding of workarounds can help healthcare facilities appreciate that workarounds are symptoms of a real or perceived workflow obstacle, and value the information that workarounds provide.
Saves, System Improvements, and Safety-II
This recurring feature highlights successes of healthcare workers in keeping patients safe; in this instance, collaboration helps prevent an incorrect anticoagulant dosage.
