The Pennsylvania Patient Safety Advisory provides timely original scientific evidence and reviews of scientific evidence that can be used by healthcare systems and providers to improve healthcare delivery systems and educate providers about safe healthcare practices. The emphasis is on problems reported to the Patient Safety Authority, especially those associated with a high combination of frequency, severity, and possibility of solution; novel problems and solutions; and problems in which urgent communication of information could have a significant impact on patient outcomes.
This special issue of the Advisory is a publication of the Patient Safety Authority's Center of Excellence for Improving Diagnosis.
The Pennsylvania Patient Safety Advisory (ISSN 1941-7144) is published quarterly, with periodic supplements, by the Pennsylvania Patient Safety Authority. This publication is produced by ECRI Institute and the Institute for Safe Medication Practices under contract to the Authority.
Copyright 2018 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed. Current and previous issues are available online at https://patientsafety.pa.gov.
This publication is disseminated by email at no cost to the subscriber. To subscribe, go to http://visitor.constantcontact.com/d.jsp?m=1103390819542&p=oi.
The Pennsylvania Patient Safety Advisory is indexed in NLM Catalog (http://www.ncbi.nlm.nih.gov/nlmcatalog), a service of the US National Library of Medicine and National Institutes of Health. The Advisory is also indexed in the CINAHL® Plus and CINAHL Plus with Full Text databases.
The Pennsylvania Patient Safety Authority works with the Pennsylvania Medical Society to offer AMA PRA Category 1 Credits™ for selected portions of the Pennsylvania Patient Safety Advisory through the online publication Studies in Patient Safety. Go to http://www.pamedsoc.org to find out more about patient safety continuing medical education opportunities. The Authority also works with the Pennsylvania State Nurses Association to offer nursing continuing education credits for selected portions of the Advisory. Go to About Us | PSNA to view the course catalog.
Manuscripts consistent with the objectives of the Pennsylvania Patient Safety Advisory are welcome. For information and guidance about submission and instructions for authors, please contact the editor.
Stanton Smullens, MD, FACS, Chair
Daniel Glunk, MD, Vice Chair
John Bulger, DO, MBA, Secretary/Treasurer
Arleen G. Kessler, PharmD, MBA, RPh
Kathleen Law, MS, BSN, RN
Mary Ellen Mannix, MRPE
Veronica Richards, Esq.
Linda Waddell, MSN, RN, CJCP, CPPS
Eric H. Weitz, Esq.
Denelle Weller, RN
Regina M. Hoffman, MBA, BSN, RN, CPPS, Executive Director
Michelle Bell, BSN, RN, FISMP, CPPS, Director, Outreach & Education
Rebecca Jones, MBA, BSN, RN, CPHRM, CPPS, Director, Innovation & Strategic Partnerships
Howard Newstadt, JD, MBA, Sr. Director, Finance & Business Operations/CIO
Caitlyn Sidrane, MPH, Manager, Communications & Publications
JoAnn Adkins, BSN, RN, CIC, Senior Infection Preventionist
Jeffrey Bomboy, BS, RN, CPPS, Patient Safety Liaison
Kelly R. Gipson, BSN, RN, CPPS, Project Manager
Lynette Hathaway, MSN, RN, CIC, Infection Prevention Analyst
Richard Kundravi, BS, CPPS, Patient Safety Liaison
Christopher Mamrol, BSN, RN, CPPS, Patient Safety Liaison
Karen McKinnon-Lipsett, Administrative Specialist
Shelly M. Mixell, Executive Assistant
Melanie A. Motts, MEd, BSN, RN, CPPS, Patient Safety Liaison
Teresa Plesce, Office Manager
Catherine M. Reynolds, DL, MJ, BSN, RN, Patient Safety Liaison
Terri Lee Roberts, BSN, RN, CIC, FAPIC, Sr. Infection Preventionist
Megan Shetterly, MS, RN, CPPS, Senior Patient Safety Liaison
Alex Ulsh, IT Systems Administrator & Deputy CISO
Katie Vivian, BSN, RN, CIC, Infection Prevention Analyst
Susan C. Wallace, MPH, CPHRM, Patient Safety Liaison
Robert Yonash, RN, CPPS, Patient Safety Liaison
Regina M. Hoffman, MBA
Rebecca Jones, MBA
Michelle Bell, BSN
Caitlyn Sidrane, MPH
William Marella, MBA, MMI, Program Director
John R. Clarke, MD, Editor Emeritus
Ellen Deutsch, MD, Editor
Jesse Munn, MBA, Managing Editor
Julia Barndt, MA
Eloise DeHaan, ELS
Susan Lafferty
Benjamin Pauldine, MS
Dawn Thomas
Tara Kolb, BFA, Manager, Media Services
Suzanne R. Gehris
Cynthia Field, BSN, RN, NE-BC, CPHQ
Michael J. Gaunt, PharmD
Matthew Grissinger, RPh, FISMP, FASCP
Kim Liberatore, MSN, RN, CPHQ
Mary C. Magee, MSN, RN, CPHQ, CPPS
Christina Michalek, BSc Pharm, RPh, FASHP
Edward Finley, BS
Michael Cohen, ScD, MS, RPh, Institute for Safe Medication Practices (ISMP)
Ronni Solomon, JD, ECRI Institute
Allen Vaida, PharmD, ISMP
Joshua Atkins, MD, PhD, Univ. of Pennsylvania Perelman School of Medicine
Mary Blanco, MSN, RN, CPHQ, Quorum Health Corporation
Lawrence M. Borland, MD, Children's Hospital of Pittsburgh of UPMC
Dorothy Borton, BSN, RN, CIC, Einstein Healthcare Network
Mark E. Bruley, BS, CCE, ECRI Institute (retired)
Vincent Cowell, MD, Temple University
David D. Eibling, MD, VA Pittsburgh Healthcare System
Grace L. Good, MA, RN, Children's Hospital of Philadelphia
Caprice C. Greenberg, MD, MPH, University of Wisconsin School of Medicine & Public Health
Janet Johnston, JD, MSN, RN
Sandra Kane-Gill, PharmD, MSc, FCCM, FCCP, University of Pittsburgh School of Pharmacy
Harold S. Kaplan, MD, Mount Sinai School of Medicine
Michael L. Kay, MD, Wills Eye Hospital, Thomas Jefferson Univ. Hospital, Pennsylvania Hosp.
Michael Leonard, MD, Kaiser Permanente, Institute for Healthcare Improvement
Mary Lou Manning, PhD, CRNP, CIC, FAAN, Thomas Jefferson University, College of Nursing
James B. McClurken, MD, FACC, FCCP, FACS, Temple University
Patrick J. McDonnell, PharmD, FASHP Temple University School of Pharmacy
Dwight McKay
Dona Molyneaux, PhD, RN, Gwynedd-Mercy College
Gina Moore, BSN, RN, CPHQ, Christiana Care Health Services
Steve D. Osborn, Saint Vincent Health Center
Ann Paris, JD, BSN, RN, FASHRM, CPHRM, LSSBB, The Guthrie Clinic
Shawna J. Perry, MD, FACEP, Univ. of Florida College of Medicine- Jacksonville
Eric Shelov, MD, Children's Hospital of Philadelphia, University of Pennsylvania
Dean Sittig, PhD, University of Texas
Amy B. Smith, PhD, Lehigh Valley Health Network
Nielufar Varjavand, MD, Drexel University
Linda Waddell, MSN, RN, CPPS, CJCP, Donald D. Wolff, Jr., Center for Quality Improvement and Innovation at UPMC
Harold C. Wiesenfeld, MD, University of Pittsburgh
Margaret Wojnar, MD, MEd, Penn State Health Dept. of Medicine
Zane R. Wolf, PhD, RN, FAAN, LaSalle University School of Nursing and Health Sciences
A special thanks to the individuals who reviewed articles for Vol. 15, Suppl. 1:
Deborah Chacosky, MS, MT(ASCP)SH, CSSGB, The Children's Hospital of Philadelphia
Jeff Cohn, MD, MHCM, Common Practice
Elizabeth A. Drozd, MS, MT (ASCP) SBB, CPPS, ECRI Institute
Robert C. Giannini, BS, NHA, CHTS – IM/CP, ECRI Institute
Kelly Gleason, PhD, RN, Johns Hopkins School of Nursing
Matthew Kristofor, MSN, MBA, CRNP, PMHNP-BC, RN, MHM Services, Gwynedd Mercy Univ.
Dwight McKay
Dona Molyneaux, PhD, RN, Gwynedd-Mercy College/Frances M. Maguire School of Nursing
Gina Moore, BSN, RN, CPHQ, Christiana Care Health Services
Timothy J. Mosher, MD, Penn State Hershey Medical Center, Penn State College of Medicine
Gabriel Nathan, MA, Thornton Wilder Society, OC87 Recovery Diaries
Ann Paris, JD, BSN, RN, FASHRM, CPHRM, LSSBB, The Guthrie Clinic
Gordon Schiff, MD, Brigham and Women's Hospital
Eric Shelov, MD, MBI, The Children's Hospital of Philadelphia, University of Pennsylvania
Dean F. Sittig, PhD, University of Texas
Erin Sparnon, MEng, ECRI Institute
Divvy Kant Upadhyay, MD, MPH, Geisinger Health System, Safer Dx Learning Lab, Division of Quality and Safety
333 Market Street - Lobby Level
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Website: http://patientsafety.pa.gov
Email: patientsafetyauthority@pa.gov
