September 2018 Pennsylvania Patient Safety Advisory

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Pennsylvania Patient Safety Advisory

September 2018, Vol. 15, No. 3

201809

See the Action Agenda for this issue.

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.