March 2019 Pennsylvania Patient Safety Advisory

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Pennsylvania Patient Safety Advisory

March 2019, Vol. 16, No. 1

201903

See the Action Agenda for this issue.

Reviews & Analyses

Patient Self-Harm in the Nonpsychiatric Setting

Acts of patient self-harm may challenge even the best-laid safety plans in unanticipated and potentially devastating ways. Pennsylvania healthcare facilities have reported more than 600 events describing intentional bodily harm outside of psychiatric settings, ranging from possession of means to self-harm to completion of a self-harm act.

Drug Shortages: Shortchanging Quality and Safe Patient Care

The struggle by healthcare providers to manage drug shortages has led to negative downstream effects on patients, including instances of unsafe or compromised practice and potentially harmful medication errors.

Exploring Vulnerability to Patient Safety Events along the Age Continuum

Attention to the event types and patterns of vulnerability that predominate in specific age cohorts may help facilities prioritize interventions.

From the Database

Incidence of Concurrent Surgery in Pennsylvania

In response to an inquiry, Patient Safety Authority analysts queried the Pennsylvania Patient Safety Reporting System database for events involving concurrent and overlapping surgery and procedures in hospitals and ambulatory surgical facilities.

Other Features

Celebrate the 2019 I AM Patient Safety Winners

The Pennsylvania Patient Safety Authority’s annual I Am Patient Safety contest promotes individuals and groups within Pennsylvania’s healthcare facilities who have demonstrated an exceptional commitment to patient safety. The nominations described scenarios of team work, high reliability, communication, innovation, event reporting, transitions of care, and more.

Are Humans the Problem in Patient Safety?

Encouraging humans to be adaptable improves their skill at navigating complexity, solving problems, and ultimately, improving patient safety.

Safety Stories: Missing the Mark

This recurring feature, in this example, highlights a hazard that exists if the individual drawing up medication does not recognize that a syringe is incorrectly marked.