Journal & Resources
Pennsylvania Patient Safety Advisory
June 2005, Vol. 2, No. 2
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Jun 01, 2005
Patient Safety Authority Update
At the one-year anniversary mark of PA-PSRS, discussion centers on how the program has improved patient safety in Pennsylvania.
Jun 01, 2005
Clostridium Difficile: A Sometimes Fatal Complication of Antibiotic Use
Several C. diff-related deaths in Pennsylvania highlight the need for medical intervention for evaluation and early treatment of C. diff-associated disease to occur more rapidly.
Jun 01, 2005
PA-PSRS Pointers: Avoiding Betadine Burns
Skin irritation and severe skin reactions may occur when wet, unevaporated Betadine solution comes in prolonged contact with the skin.
Jun 01, 2005
The Five Rights: Not the Gold Standard for Safe Medication Practices
While the Five Rights are essential goals of medication administration, they do not address the human factors and systems-related causes of errors.
Jun 01, 2005
PA-PSRS Pointers: Watch Out for that Dermabond
Event reports describe cases in which patients' eyelids were inadvertently glued shut while Dermabond was applied to facial lacerations.
Jun 01, 2005
A Different Mindset: One Facility's Experience with the Anonymous Report Process
Lessons learned from an Anonymous Report filed under Act 13 include agreements about the definition of a Serious Event, event reporting, and peer review of potentially reportable events.
Jun 01, 2005
Risk of Fire From Alcohol-Based Solutions
While flammable liquid germicides are good antimicrobial agents, their misuse can present a significant fire hazard.
Jun 01, 2005
Poor Labeling of Respiratory Therapy Medications Can Impact Patient Safety
Look-alike packaging and embossed labeling may contribute to medication errors with respiratory medications.
Jun 01, 2005
Tips from PA Facilities: Enforcing the Time Out and Preventing Retained Foreign Bodies
Experiences of Pennsylvania facilities’, conveyed through event reports, include suggestions to minimize the potential for a procedure to begin without a time out and actions to help prevent occurrence of retained foreign bodies.
Jun 01, 2005
Spotted Again: Insulin/TB Syringe Confusion
An event report about insulin and tuberculin syringe confusion prompts revisiting this topic, which was first highlighted in the October 28, 2004, supplementary Advisory.
Jun 01, 2005
Forgotten But Not Gone: Tourniquets Left on Patients
Simple, practical tips developed by clinicians may help to reduce the systemic problem of tourniquets left on patients.
Jun 01, 2005
Unintended Lacerations or Punctures During Surgery
The most frequently cited procedures and sites involved with unintended lacerations or punctures during surgery are identified.
Jun 01, 2005
PCA by Proxy—An Overdose of Care
When used as intended, patient-controlled analgesia (PCA) reduces the risk of oversedation; however, incorrect use by individuals other than the patient can place the patient at risk for over-sedation, respiratory depression, and even death.
Jun 01, 2005
Skin Integrity Issues Associated with Pulse Oximetry
Event reports indicated that patients have sustained skin integrity injuries during pulse oximetry, including discolorations, blisters, lacerations, burns, and necrosis.
Jun 01, 2005
Complexity of Insulin Therapy
Nearly 16% of Serious Events submitted through PA-PSRS involved the use of insulin, a high-alert medication.