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Journal & Resources
PATIENT SAFETY journal
News
Training & Events
Related Organization Links
Advisory Archive
Pennsylvania Patient Safety Advisory
Advisory Archive
September 2018, Vol. 15, No. 3
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Reviews & Analyses
Adapting Verification Processes for Preventing Wrong Radiology Events
Developing and implementing verification processes specific to the medical-imaging care continuum is essential to reduce the risk of harm from wrong radiology events.
The Breakup: Errors when Altering Oral Solid Dosage Forms
These errors may disproportionately impact vulnerable patient populations with dysphagia in acute care, rehabilitation, and long-term care facilities.
Speaking Up for Safety—It’s Not Simple
To evaluate engagement of Pennsylvania patients in common safety practices, the Pennsylvania Patient Safety Authority developed a poll, which was administered in 2006, 2013, and most recently, 2018. Reported engagement varied among the safety practices in 2018, but the ranking of the safety practices by positive inclination remained relatively consistent.
Focus on Infection Prevention
A Second Breadth: Hospital-Acquired Pneumonia in Pennsylvania, Nonventilated versus Ventilated Patients
Recent analysis finds not only that nonventilator hospital-acquired pneumonia continues to be as lethal as ventilator-associated pneumonia, but that it demonstrates higher incidence and is more costly as a whole.
Other Features
Safety Stories: A Weighty Problem
This vignette presents a brief, timely highlight of a patient weight event reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) that may provide a learning opportunity for facilities.
Safety Stories: Site Marks
This vignette presents a brief, timely highlight of surgical site marking events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) that may provide a learning opportunity for facilities.
Principles for Reliable Performance of Correct-Site Nerve Blocks
An initiative between the Pennsylvania Patient Safety Authority and the Pennsylvania Society of Anesthesiologists assesses the frequency of wrong-site nerve blocks and presents Pennsylvania anesthesia providers and healthcare facilities with practices to prevent them.
A New Pairing: Root Cause and Success Analysis
Root cause analysis is commonly used in attempts to improve the safety of healthcare delivery, but a variation—success analysis—may also be useful.