Journal & Resources
Pennsylvania Patient Safety Advisory
September 2007, Vol. 4, No. 3
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Patient Safety Authority: Partners in Risk Management
Allied Services Rehabilitation Hospital representatives share their foundation for successful change built on teamwork and leadership.
Drug Labeling and Packaging—Looking Beyond What Meets the Eye
The design of medication packaging and labeling can contribute to errors such as incorrect drug dispensing. Factors such as readability, expression of drug strength or concentration, use of color, and lack of contrast can all affect the potential for an error to occur.
Authority Board Approves Infection Control Advisory Panel
The Patient Safety Authority’s Board of Directors approves a 13-member panel of infection control experts to help implement Act 52 of 2007.
Query on Wrong-Site Surgery
A reader questions whether the analysis of wrong-site surgery events reported in Pennsylvania and the resulting article adequately addresses the responsibility of physicians in preventing wrong-site surgery.
Diligence and Design in Behaviorial Health Impact Patient Safety
Many patients admitted to behavioral health facilities are at risk for harming themselves or others; however, facilities can address the associated risk factors using risk reduction strategies discussed in this article.
Three Never Complications of Surgery Are Hardly That
When undergoing an operation, a patient should never have to accept these three complications as risks of surgery.
The Time for Transfer of Trauma Patients to Accredited Trauma Centers Can Impact Quality and Timeliness of Patient Care
Community hospitals that establish transfer agreements with trauma centers can optimize and expedite patient care, and the hospitals may realize additional benefits (e.g., cost savings), too.
Profitability is Associated with Reporting Patient Safety Events
There is a small, yet significant relationship between the number of reports per licensed bed of an acute care hospital and its operating margin, according to analysis of reports submitted to PA-PSRS and the Pennsylvania Health Care Cost Containment Council’s 2006 financial report.
Inadvertent Mix-Up of Morphine and Hydromorphone: A Potent Error
Hydromorphone is a common alternative to morphine; however, hydromorphone’s analgesic equivalence must be considered because it is more potent than morphine when administered by any route.
Common Medication Pairs that Contribute to Wrong Drug Errors
Confusing pairs of look-alike and sound-alike medications are frequently involved in wrong drug errors; here, PA-PSRS lists the top 25 medication pairs cited in submitted reports.
Distribution of Event Types in ASFs versus Hospitals
Reports of unplanned returns to the operating room in ambulatory surgical facilities may indicate an opportunity for quality improvement.
Obstructive Sleep Apnea May Block the Path to a Positive Postoperative Outcome
The majority of patients with obstructive sleep apnea are undiagnosed. Anesthesia providers can easily screen for this condition to avoid problems with airway management during anesthesia administration.
IV Infiltration: Be Alarmed Even When Your Infusion Pump Isn't
Reports of infiltration and extravasation indicate that some clinicians may misunderstand the role of occlusion alarms on infusion pumps.
Preventing Adverse Events Related to Chest Tube Insertion
A tutorial program for physicians that discusses four sources of adverse outcomes during chest tube insertion (e.g., incorrect surgical technique) is available from the U.S. Agency for Healthcare Research and Quality. Examples of these sources of adverse outcomes are apparent in reports to PA-PSRS.
Should Patients be Accompanied When Discharged from Ambulatory Surgery?
This article addresses the issue of ambulatory surgery patients and responsible escorts, including the practice of letting patients take public transportation home following discharge.
Deaths Following Ambulatory Surgery
Analysis of reports of patient deaths following ambulatory surgery emphasizes the need for ambulatory surgical facilities to be able to respond to emergency conditions.
The Big Picture
Janet Johnston, RN, MSN, JD, retires from her position as a PA-PSRS patient safety analyst and shares her insight on the importance of recognizing the relationship between individual health-related tasks and the patient’s overall care.