December 2018 Pennsylvania Patient Safety Advisory

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Pennsylvania Patient Safety Advisory

December 2018, Vol. 15, No. 4

201812

See the Action Agenda for this issue.

Reviews & Analyses

Strict attention to magnetic resonance imaging (MRI) screening to prevent ferromagnetic objects and devices from reaching the MR scanner’s magnetic field is important for safe MRI. Significant injury can occur to individuals in the MR scanner suite if a ferromagnetic object or a device with ferromagnetic components is exposed to the magnetic field and radiofrequency energy of the MRI.

Perioperative Medication Errors: Uncovering Risk from Behind the Drapes

Medication use in the perioperative setting presents unique patient safety challenges compared with other hospital settings. Organizations may use this data to inform proactive efforts to standardize protocols in the perioperative setting and prevent errors from occurring.

Are You Ready to Respond? Reports of High Harm Complications after Surgery and Invasive Procedures

Surgery and other invasive procedures carry risk of complication and mortality, but recognizing and responding rapidly to such complications can improve patient outcomes.

From the Database: Deaths after Ambulatory Surgery

In the 10 years analyzed, the number of ASF cases increased annually, while the rate of reports involving death remained stable. ASFs may benefit from incorporating into risk reduction efforts the patterns identified as associated with higher risk, as well as the shared strategies and resources.

Focus on Infection Prevention

How Wet Is Your Patient’s Bed? Blood, Urine, and Microbiological Contamination of Mattresses and Mattress Covers

Body fluid and microbiological contamination can remain on, or within, mattresses and mattress covers after cleaning. To reduce this risk, joint initiatives to address inadequate mattress cover reprocessing and deficient inspection of mattresses and mattress covers may be needed.

Other Features

Safety Stories: It Takes a Village

This recurring feature highlights, in these examples, how diverse people, with different roles, each contribute to making patient care safer.

Why are Safety Stories Important?

As providers, staff and leaders seek lifelong learning and ongoing improvement, and they can find valuable lessons in understanding “what went well.”