Nearly 900 medication error reports listed health information technology (HIT) as a factor contributing to the event submitted to the Pennsylvania Patient Safety Authority. The most common HIT systems implicated in the events were the computerized prescriber order entry system, the pharmacy system, and the electronic medication administration record.
Hospitals can decrease the risk for gastrointestinal tube complications by implementing best practices and risk reduction strategies to confirm proper positioning of gastrostomy tubes and to prevent, recognize, and manage dislodgement. Aside from peritonitis, sepsis, and death, other serious harm can result from even minor changes in gastrostomy tube position.
Handoffs are an integral part of care coordination and the delivery of safe patient care. Using handoff processes that incorporate critical thinking and reasoning skills to address patient needs and providing handoff training and education are strategies to improve patient handoff communications.
Surgical items such as sponges, sharps, and instruments may be retained during surgery and can lead to serious patient harm. Detecting and reporting retained surgical items may help to determine patterns and root causes using a definition decided upon by the healthcare facility.
Influenza is a contagious respiratory illness that can cause mild to severe illness and can lead to death. Long-term care facilities can promote influenza vaccination each season by reducing barriers to healthcare personnel vaccination.
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 Authority congratulates the individuals recognized for their efforts to improve patient safety in Pennsylvania’s healthcare facilities, and applauds their commitment.
The challenge in managing the potential for data overload is to determine the ideal middle ground between excessive data and insufficient information and to arrange the relevant information in a manner that supports clinicians’ cognitive processes.
This recurring feature highlights successes of healthcare workers in keeping patients safe; in this instance, an experienced nurse catching a near 10-fold overdose of medication.
This is the table of contents for the March 2017 Pennsylvania Patient Safety Advisory
Healthcare facilities can help reduce the opportunity for drug interactions reaching patients by addressing all areas of the medication-use process and not relying solely on the effectiveness of alerts when orders are entered into electronic health records.
Fostering an environment that supports effective patient safety programs is inherent to the Authority’s mission. A select set of patient safety measures were chosen to demonstrate the results of the combined efforts of Pennsylvania healthcare facilities, statewide quality improvement entities, and the Authority to improve patient safety.
The survey results from the national project revealed that the tools were valuable to the majority of respondents by improving catheter-associated urinary tract infection (CAUTI) identification, process and outcome measurement, CAUTI case root-cause analysis, and CAUTI prevention and control measures.
Accidental injection of oral nimodipine for patients unable to swallow may result in severe hypotension, cardiovascular collapse, or cardiac arrest.
Analysis of wrong-site events reported by ambulatory surgical facilities identified an increase in these reported events over time.
A request to update data from an 2009 article led Pennsylvania Patient Safety Authority analysts to query the reporting database for maternal events. The most common maternal Serious Events reported are laceration of the birth canal, postpartum hemorrhage, and bladder laceration.
Reporting unsafe conditions identified during simulation to the Pennsylvania Patient Safety Authority may expand knowledge and advance patient safety.